NCLEX 2025 question

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110 terms kandykat1012Preview Archer NCLEX Study Bank Question...152 terms Kimberly_Peacock47 Preview nclex s 46 terms sofi The nurse has instructed a client who has a newly prescribed transcutaneous electrical nerve stimulation (TENS) unit. Which of the following statements by the client indicates a correct understanding of the teaching?

• "I should not take pain medications while this device is

applied."

• "I will adjust the current to the point at which I

experience a sensation of pins and needles."

• "The electrodes will be placed all over my body."
• "I should experience generalized twitching while this

device is applied." Choice B is correct. A transcutaneous electrical nerve stimulation (TENS) unit is an over-the-counter pain-relieving device that provides a counter-current to an area of localized pain. The electrodes are placed where the area of pain is, and the current is adjusted until the client feels a 'pins and needles sensation which is theorized to release endorphins. TENS units are commonly used as adjunctive pain relief for musculoskeletal pain.Choices A, C, and D are incorrect. A TENS unit is an adjunctive pain relieving device and may be used with other modalities such as acetaminophen, naproxen, etc. The electrodes are not applied all over the client's body; they are applied to where the client is experiencing the pain. Generalized twitching is not the expected sensation of the TENS unit; it is a pins-and-needles sensation experienced where the pain is localized.

• edema
• tenderness

Choice C is correct. The client should be advised to monitor for edema in one leg as a sign of postpartum thrombophlebitis. If swelling is noted, the nurse should measure both lower extremities and compare the circumference of the affected with the unaffected.Choice D is correct. The client should be advised to monitor for tenderness in one leg as a sign of postpartum thrombophlebitis. Edema, pain, and redness would be expected findings in whichever leg the clot is occluding.Choice A is incorrect. An individual with thrombophlebitis has localized pain, erythema, heat, and tenderness.Muscle weakness in the extremity is not an expected finding and could suggest hypokalemia.Choice B is incorrect. Ulcers between the toes are a clinical manifestation associated with peripheral arterial disease. This is not a symptom associated with thrombophlebitis.Choice E is incorrect. Cyanosis (bluish discol

• edema
• tenderness

Choice C is correct. The client should be advised to monitor for edema in one leg as a sign of postpartum thrombophlebitis. If swelling is noted, the nurse should measure both lower extremities and compare the circumference of the affected with the unaffected.Choice D is correct. The client should be advised to monitor for tenderness in one leg as a sign of postpartum thrombophlebitis. Edema, pain, and redness would be expected findings in whichever leg the clot is occluding.Choice A is incorrect. An individual with thrombophlebitis has localized pain, erythema, heat, and tenderness. Muscle weakness in the extremity is not an expected finding and could suggest hypokalemia.Choice B is incorrect. Ulcers between the toes are a clinical manifestation associated with peripheral arterial disease. This is not a symptom associated with thrombophlebitis.Choice E is incorrect. Cyanosis (bluish discoloration of the skin) or coolness in one limb is a sign of venous obstruction, not thrombosis. Instead, when monitoring for signs of postpartum thrombophlebitis, the client should be instructed to report symptoms of inflammation such as warmth, swelling, or redness.Choice F is incorrect. Patches of hair loss are a manifestation associated with arterial insufficiency. Because of the decreased blood flow, less hair grows on the skin.The nurse is performing an assessment on a newborn.Which findings require follow-up?Select all that apply.

• high pitched cry
• heart rate 175/minute while crying
• white patches on cheeks or tongue
• vernix caseosa in the creases
• respiratory rate 25/minute
• high pitched cry
• white patches on cheeks or tongue
• respiratory rate 25/minute

Choice A is correct. A high-pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome or a sign of increased ICP if there is birth trauma. The expectation is that the cry is vigorous but not high- pitched.Choice C is correct. White patches on the cheeks and tongue are a finding that requires follow-up because this may indicate candidiasis. Epstein's pearls may be present on the hard palate or gums, which is a benign finding.Choice E is correct. A respiratory rate of 25/minute requires follow-up because the expected respiratory rate for a newborn is 30 to 60 breaths per minute.Choice B is incorrect. A heart rate (pulse) of 175/minute is expected for a newborn who is crying. An expected heart rate for a newborn is 120 to 160 bpm (100 sleeping, 180 crying).Choice D is incorrect. Vernix caseosa, a thick white substance that resembles cream cheese, provides a protective covering for the fetal skin in utero. This is a normal finding. Vernix caseosa protects fetal skin from constant exposure to amniotic fluid.

The nurse conducts a review course on older adults and medication elimination/excretion.It would be appropriate for the nurse to note which factor may impact drug elimination? Select all that apply.

• Diminished glomerular filtration
• Decreased hepatic enzyme functioning
• Decreased peristalsis
• Lower pH of the gastric secretions
• Increased acidity of the gastric secretions
• Low functioning nephrons
• Diminished glomerular filtration
• Low functioning nephrons

Choices A is correct. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body is the aging population's diminished glomerular filtration. This change can lead to the accumulation of medications in the body because they are not properly eliminated Choice F is correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body is the aging population's low-functioning nephrons. This change can lead to the accumulation of medications in the body because they are not properly eliminated.Choice B is incorrect. Decreased hepatic enzyme functioning slows down the metabolism of medications, but not the excretion and elimination of medications in the human body.Choice C is incorrect. Decreased peristalsis slows down the absorption of medications, but not the excretion and elimination of drugs in the human body.Choice D is incorrect. Increased pH of the gastric secretions, rather than lower pH, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body.Choice E is incorrect. Increased alkalinity, not acidity, slows down the absorption of medications, but not the excretion and elimination of drugs in the human body.A pregnant client at 37 weeks gestation arrives at the

hospital with the following signs and symptoms: severe

headache, blurred vision, and epigastric pain not relieved by pain medication. The client's blood pressure is 160/110 mm Hg. The nurse suspects the client is experiencing which condition?

• Preterm labor
• Ectopic pregnancy
• Severe preeclampsia
• Pre-eclampsia
• Severe preeclampsia

Choice C is correct. Severe preeclampsia is characterized by high blood pressure, proteinuria (presence of protein in urine), and organ dysfunction. It is a serious condition that requires immediate medical intervention to prevent complications for both the mother and the baby.Severe preeclampsia is diagnosed If one or more of the following criteria are

present:

Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic or higher on two occasions at least 6 hr apart while the client is on bed rest Oliguria of <500>

Choice D is incorrect. Preeclampsia is classified as:

Occurring after 20 weeks of pregnancy BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic or higher Proteinuria 0.3 g protein or higher in a 24-hour urine specimen or ≥ +1 per dipstick or P/C ratio ≥0.3 mg/dL

A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?(a) A client requiring colostomy irrigation (b) A client receiving continuous tube feedings (c) A client who requires stool specimen collections (d) A client who has difficulty swallowing food and fluids Correct answer: (c) A client who requires stool specimen collectionsRationale: This question addresses content related to delegation in the subcategory Management of Care in the Client Needs category of Safe and Effective Care Environment. Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. In this situation, the most appropriate assignment for the nursing assistant is to care for the client who requires stool specimen collections. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Remember, the health care provider needs to be competent and skilled to perform the assigned task or activity.The patient presents to the emergency department with chest pain. Which description of the pain prompts the nurse to suspect a myocardial infarction?

• Gnawing, burning chest pain
• Crushing chest pain
• Ripping pain in the chest and back
• Pain that is worse when the ribs are pressed
• Crushing chest pain

Chest pain associated with myocardial infarction (MI) is classically described as crushing chest pain, which may radiate to the jaw or arm. MI pain may occur with or without exertion, and is accompanied with anxiety, sweating, nausea, vomiting, and dyspnea, and may last longer than 30 minutes. Gnawing, burning pain in the chest is more indicative of heartburn. A ripping chest and back pain is more consistent with an aortic dissection. Pain that gets worse when pressing on the ribs is likely musculoskeletal, and certainly not from coronary artery disease.The patient intubated in the intensive care unit has the

following arterial blood gas results:

pH 7.21

PCO2 51

PaO2 38

HCO3 16

Base Excess -7 Which action does the nurse take first?

• Contact the provider to come assess the patient
• Assess the need for increased sedation or pain

medication

• Ensure airway patency and provide endotracheal

suctioning

• Increase the fraction of inspired oxygen being

delivered to the patient

• Increase the fraction of inspired oxygen being delivered to the patient

Rationale The patient is hypercapnic, acidotic, and significantly hypoxemic based on the blood gas results. The first intervention is to increase the fraction of inspired oxygen being delivered to the patient to alleviate the hypoxemia. Suctioning without preoxygenating the patient can lead to further decompensation, so airway patency and suctioning is performed after the FiO2 is increased. The need for increased sedation or pain medication can take place now, as well. Once these immediate interventions have been tried, the provider should come to assess the patient to determine if increased ventilatory support is needed, like an increased ventilation rate.The 72-year-old male patient was recently diagnosed with prostate cancer. The nurse anticipates which additional complaint?

• Correct
• Hot flashes
• Urinary retention
• Gynecomastia
• Urinary retention

Rationale In some cases of prostate cancer, the tumor places pressure on the urethra or urinary bladder, which obstructs the path of urine through the urethra. Urinary retention is a serious clinical condition that needs immediate medical attention.Hot flashes, gynecomastia, and GI symptoms are known side-effects of flutamide, which is a treatment for prostate cancer.