Nursing Care Instructions and Interventions, Exams of Nursing

Download Nursing Care Instructions and Interventions and more Exams Nursing in PDF only on Docsity! 1 NCLEX-PN 2024 TEST BANK 200+ REAL EXAM PRACTICE QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ The nurse is caring for a client scheduled for removal of a pituitary tumor using the transphenoidal approach. The nurse should be particularly alert for? - CORRECT ANSWER>>>Nasal Congestion A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? - CORRECT ANSWER>>>Hypokalemia A 24 yr old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? - CORRECT ANSWER>>>Taking the Vital Signs The nurse is working in the ER when a client arrives with severe burns of the left arm , hands, face and neck. Which action should receive priority? - CORRECT ANSWER>>>Applying oxygen The nurse is caring for a client with osteoporosis. The client has a new prescription for alendronate(Fosamax). Which instruction should be given to the client? - CORRECT ANSWER>>>Take with water only The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? - CORRECT ANSWER>>>A torque wrench The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse should tell the client to perform which action? - CORRECT ANSWER>>>Wrap a plastic bag filled with ice 2 The nurse removes a clients surgical abdominal dressing and notes a thin yellow drainage, separation of the incision line, and the presence of underlying tissue. The nurse should take which priority action? - CORRECT ANSWER>>>Apply a sterile dressing soaked with normal saline The nurse is reinforcing teaching to a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? - CORRECT ANSWER>>>Sit upright when using the device The nurse is collecting data from a client notes that the clients left eyelid is drooping. The nurse documents that the client is exhibiting which condition? - CORRECT ANSWER>>>Ptosis The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The lesions are open and draining a scant amount of serous fluid. Which precaution should the nurse ensure is followed by all health care workers? - CORRECT ANSWER>>>Contact The nurse suspects a foreign body airway obstruction (FBAO) in a responsive infant. The nurse plans to relieve the obstruction by performing which action? - CORRECT ANSWER>>>Delivering 5 back slaps and 5 chest thrusts The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms would be noted in severe preeclampsia? - CORRECT ANSWER>>>Oliguria Proteinuria 3+ Blood pressure 168/116 mm Hg Which client is at greatest risk for fluid volume deficit? - CORRECT ANSWER>>>The client on diuretic therapy Which safety measures should be included in the plan of care for a client with an internal radiation implant? - CORRECT ANSWER>>>*Wear a lead shield when in the clients room. *Wear a dosimeter badge when entering the clients room. *Save bed linens and any dressings until the implant is removed. 5 *Stay with the child *Move furniture away from the child The nurse, reinforcing home care instructions, prepares a list for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? - CORRECT ANSWER>>>*Keep small toys and sharp objects away from the cast . *Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. *Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? - CORRECT ANSWER>>>*Frequent hand washing is important. *The child should avoid exposure to other illnesses. *Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). The health education nurse reinforces instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse reinforce to the client? - CORRECT ANSWER>>>*Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. *Examine your body monthly for any lesions that may be suspicious. The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which may be prescribed to treat this complication? - CORRECT ANSWER>>>*Radiation 6 *Chemotherapy *Serum sodium blood levels *Medication that is antagonistic to antidiuretic hormone (ADH) The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? - CORRECT ANSWER>>>*Dry Skin *Constipation *Cold intolerance The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? - CORRECT ANSWER>>>*Diarrhea can occur secondary to the metformin. *The repaglinide is not taken if a meal is skipped. *The repaglinide is taken 30 minutes before eating. *Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes. The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? - CORRECT ANSWER>>>*Insomnia *Weight loss 7 *Mild heat intolerance The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? - CORRECT ANSWER>>>*Administer antacids, as prescribed. *Encourage coughing and deep breathing. *Administer anticholinergics, as prescribed. A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? - CORRECT ANSWER>>>*Nizatidine (Axid) *Ranitidine (Zantac) *Famotidine (Pepcid) *Cimetidine (Tagamet) The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? - CORRECT ANSWER>>>*Activities should be resumed gradually. *A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. *Respiratory isolation is not necessary because family members have already been exposed. *Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 10 *Place the client in good body alignment. *Check the peritoneal dialysis system for kinks. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? - CORRECT ANSWER>>>*To avoid activities that require bending over *To place an eye shield on the surgical eye at bedtime *To place an eye shield on the surgical eye at bedtime *To take acetaminophen (Tylenol) for minor eye discomfort The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? - CORRECT ANSWER>>>*Wash hands. *Put on gloves. *Place the drop in the conjunctival sac. *Place the drop in the conjunctival sac. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? - CORRECT ANSWER>>>*Pad the bed's side rails. *Place an airway at the bedside. *Place oxygen equipment at the bedside 11 *Place suction equipment at the bedside The client is receiving meperidine hydrochloride (Demerol) for pain. Which are side/adverse effects of this medication? - CORRECT ANSWER>>>*Tremors *Drowsiness *Hypotension The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? - CORRECT ANSWER>>>*Keep the cast and extremity elevated. *The cast needs to be kept clean and dry *Allow the wet cast 24 to 72 hours to dry. In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse interpret as acceptable responses - CORRECT ANSWER>>>*Symptom control during periods of emotional stress *Normal white blood cell, platelet, and neutrophil counts *Radiological findings that show nonprogression of joint degeneration *An increased range of motion in the affected joints 3 months into therapy Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy? - CORRECT ANSWER>>>*Use nonlatex gloves. *Use medications from glass ampules. 12 *Use medications from glass ampules. Keep a latex-safe supply cart available in the client's area. A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which side/adverse effects of the medication? - CORRECT ANSWER>>>*Rash *Hepatotoxicity Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include in the plan of care regarding this medication? - CORRECT ANSWER>>>*Instruct the client to avoid alcohol. *Monitor hepatic and liver function studies. *Instruct the client to avoid exposure to the sun. The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? - CORRECT ANSWER>>>*Restating *Listening *Maintaining neutral responses *Providing acknowledgment and feedback Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? - CORRECT ANSWER>>>*Communicate expected behaviors to the client. 15 The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? - CORRECT ANSWER>>>*Dyspnea on exertion *Presence of a productive cough *Difficulty breathing while talking The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? - CORRECT ANSWER>>>*Apply disposable gloves. *Lubricate the enema tube and insert it approximately 4 inches. *Clamp the tubing if the client expresses discomfort during the procedure. *Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C). The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? - CORRECT ANSWER>>>*Obtain a Medic-Alert bracelet. *Prevent debris from entering the stoma. *Avoid exposure to people with infections. *Avoid swimming and use care when showering. The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? - CORRECT ANSWER>>>*Instruct the client about thyroid replacement therapy. 16 *Encourage the client to consume fluids and high-fiber foods in the diet. *Instruct the client to contact the health care provider if episodes of chest pain occur. The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? - CORRECT ANSWER>>>*Open the distal flap of a sterile package first. *Prepare the sterile field just before the planned procedure. *Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field. The nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? - CORRECT ANSWER>>>*Tinnitus *Hypotension *Hypokalemia The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? - CORRECT ANSWER>>>*Change the password for entering computer files at least monthly. *Shred the printout of the nurse's flowchart at the end of the nurse's shift. *Use own user name and password when logging into the computer system. Which guidelines should the nurse follow when performing narrative documentation? - CORRECT ANSWER>>>*Date and time entries. 17 *Sign and title each entry. *Avoid judgmental and evaluative statements. Do not leave blank spaces on documentation forms The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? - CORRECT ANSWER>>>*Tetany *Diarrhea *A positive Trousseau's sign The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? - CORRECT ANSWER>>>*Gentamicin 8 mcg/mL *Theophylline (Theo-24) 10 mcg/mL *Carbamazepine (Tegretol) 10 mcg/mL The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? - CORRECT ANSWER>>>*Tofu *Broccoli *Sardines *Mustard greens 20 *White blood cells, 3000 cells/mm3 WBC 4500 to 11,000 cells/mm3 serum creatinine, 0.6 to 1.3 mg/dL calcium, 8.6 to 10.0 mg/dL TSH 0.2 to 5.4 microunits/mL magnesium, 1.6 to 2.6 mg/dL BUN magnesium, 1.6 to 2.6 mg/dL The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? - CORRECT ANSWER>>>*Ensure the client doesn't sit or stand for long periods of time. Ensure the client doesn't cross the legs past the midline of the body. *Ensure the client uses assistive/adaptive devices with activities of daily living. A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? - CORRECT ANSWER>>>*Broth *Coffee *Geletan The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? - CORRECT ANSWER>>>*Prune juice *Apple juice *Cranberry juice 21 Which safety measures that should be implemented when working in the newborn nursery? - CORRECT ANSWER>>>*Adhere to standard precautions. *The parents should be instructed to not release their infant to anyone wearing improper identification. *The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room. The advantages of using spinal anesthesia for delivery of a fetus include which? - CORRECT ANSWER>>>*Ease of administration *Absence of fetal hypoxia *Immediate onset of anesthesia Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? - CORRECT ANSWER>>>*Give the child a teaspoon of honey. *Prepare to administer glucagon subcutaneously if unconsciousness occurs Which interventions should the nurse include when preparing a plan of care for a child with hepatitis? - CORRECT ANSWER>>>*Providing a low-fat, well-balanced diet *Teaching the child effective hand-washing techniques *Instructing the parents about the risks associated with taking medications The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? - CORRECT ANSWER>>>*Pedal pulses 22 *Capillary refill *Color of the extremity *Temperature of the skin The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? - CORRECT ANSWER>>>*Reducing environmental noise *Maintaining a calm atmosphere *Allowing the client uninterrupted time for sleep The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? - CORRECT ANSWER>>>*Eat a nutritious diet. *Use a pressure relief pad while in a wheelchair. *Check the bottom sheet for wetness and wrinkles. The nurse provides information to the mother of a toddler regarding toilet-training. The nurse should tell the mother what information? - CORRECT ANSWER>>>*The child should not be forced to sit on the potty for long periods." *"The ability of the child to remove clothing is a sign of physical readiness." *"Waiting until the child is 24 to 30 months old makes the task considerably easier." 25 A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? . - CORRECT ANSWER>>>"My husband always brings me flowers and apologizes after he hits me." "My boyfriend yells and accuses me of having an affair if I am late after work." "I have bruises all over my body. I am frequently clumsy and fall a lot." A client is monitoring a client receiving theophylline (Theo-24) to treat symptoms of chronic obstructive pulmonary disease (COPD). Which adverse effects require immediate consultation with the health care provider? - CORRECT ANSWER>>>*Seizures *Irregular heartbeat The nurse is providing client teaching regarding glaucoma. Which instructions are important to include in the teaching plan? - CORRECT ANSWER>>>*Follow a low-sodium, minimal-caffeine diet with plenty of fiber. *Be sure to report halos of light or increased eye pain to your health care provider. A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? - CORRECT ANSWER>>>Ask a member of the local ostomy club to visit with the client before discharge. Ask the enterostomal nurse specialist to consult with the client before discharge. Ask the client to begin doing one part of the ostomy care and increase tasks daily. The nurse is assisting in developing a postoperative plan of care for a client following a mastectomy. Which interventions will be included in the plan of care? . - CORRECT ANSWER>>>Place the affected arm on a pillow. 26 Check the incision for signs of infection. Monitor and measure drainage in the collection device. The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is consistent with dystocia? - CORRECT ANSWER>>>Signs of fetal distress High level of maternal anxiety Failure of the fetus to descend The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate a understanding of the implications of the client's symptoms? - CORRECT ANSWER>>>"Lie on your left side for an hour and try to drink some fluids." "It is important that you urinate frequently to keep your bladder empty." "Palpate for contractions and call back if there are more than four contractions in the next hour." "Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?" Auranofin (Ridaura) has been prescribed for a client with rheumatoid arthritis. The nurse who is collecting data 2 weeks later interprets that the client may be experiencing the signs of medication toxicity based on what data collection findings? - CORRECT ANSWER>>>Observes several mouth lesions Notes a rash noted on trunk and neck Notes a rash noted on trunk and neck 27 Notes purplish blotches on the skin The nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. The nurse understands that which intervention should be included? - CORRECT ANSWER>>>Rest Local heat Analgesics The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? - CORRECT ANSWER>>>Allowing the client sufficient time to eat Providing oral hygiene after each meal Maintaining a suction machine at the bedside The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? - CORRECT ANSWER>>>Suction machine Oxygen administration Padding for the side rails Prescribed diazepam (Valium) The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection? - CORRECT ANSWER>>>Protein level of 20 mg/dL 30 The nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further teaching? - CORRECT ANSWER>>>"I need to limit playing football to only the weekends." "I should exercise in the evening to encourage a good sleep pattern." The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis? - CORRECT ANSWER>>>Early onset cough Purulent mucous production Mild episodes of dyspnea The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? - CORRECT ANSWER>>>Mouthwash A soft toothbrush Oral suction catheter Bite stick or a padded tongue blade The nurse assigned to care for a hearing-impaired client should use which approach to communication in order to enhance communication and preserve the client's self-esteem? - CORRECT ANSWER>>>Speaking slowly and clearly Standing directly in front of the client while speaking Turning down the volume on the radio or TV when talking 31 The nurse is preparing to instill an otic solution into the adult client's right ear. The nurse should include which action while performing this procedure? - CORRECT ANSWER>>>Pulling the auricle of the right ear upward Pulling the auricle of the right ear backward Warming the solution to room temperature Placing the client in a left side-lying position A client has sought treatment in the ambulatory care clinic after an insect has become trapped in the external ear canal. The nurse prepares to assist the health care provider to instill which acceptable solutions into the ear to remove the insect? - CORRECT ANSWER>>>Lidocaine Mineral oil Ether solution clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. Which recommendation by the nurse is therapeutic? - CORRECT ANSWER>>>Get plenty of rest. Take antipyretics for fever. Increase intake of liquids. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? - CORRECT ANSWER>>>Eat smaller and more frequent meals. Drink fluids between meals not with them. 32 The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? - CORRECT ANSWER>>>Eat small frequent meals. Take action to prevent dumping syndrome. A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should tell the client about the need for which? - CORRECT ANSWER>>>Iron supplements Calcium supplements Vitamin B12 injections The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions should the nurse provide to the client? - CORRECT ANSWER>>>Protect the stoma from water. Soaps should be avoided near the stoma. Wash the stoma daily using a washcloth. Apply a thin layer of petroleum jelly to the skin surrounding the stoma. The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? - CORRECT ANSWER>>>Monitor the client's ability to void. Maintain the client in a flat position. Monitor the client's ability to move the extremities.