NCLEX Final ATI - (ELISA) testing and is diagnosed as being human...

NCLEX Final ATI An 18 month old infant admitted with Pneumocystis carinii pneumonia has enzyme linked immunosorbent assay (ELISA) testing and is diagnosed as being human immunodeficiency virus (HIV) positive. In planning care, the nurse should be aware that the infant's mother is also HIV positive.

An adolescent client who has had no prenatal care is admitted in labor and gives birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses is appropriate from the nurse at this time?"I am so sorry that this has happened."

After 30 min of rambling about the "ozone layer" and being "doomed to die," a client begins pacing in an increasingly agitated manner. What should the nurse do first?Remain with the client and attempt to reduce the environmental stimuli.

After an exploratory laparotomy, a client is admitted to the medical surgical unit with an indwelling urinary catheter and a Jackson Pratt (JP) drainage tube. Which finding should indicate to the nurse that the client may be experiencing a postoperative complication?Pulse oximetry of 85%

At a maternal health clinic, a nurse talks with several prenatal clients on the phone. Which client report does the nurse realize is a normal physiologic adaptation to pregnancy?Breast tenderness

At the first prenatal visit, a nurse learns that a pregnant client is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client?Collard greens

A charge nurse on a pediatric floor receives the results from the morning laboratory work. Which of the following client results will require the nurse call to the primary care provider first?A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL

A client admitted with borderline personality disorder is expressing concern about requiring a prolonged hospitalization. What is the therapeutic statement the nurse could make when interacting with this client?"Tell me what concerns you the most about being hospitalized."

A client asks the nurse if it is common to experience vaginal yeast infections during pregnancy. Which of the following is an appropriate response?"The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common."

A client being treated for antisocial personality disorder is becoming increasingly loud and belligerent on the mental health unit. Which approach should the nurse use to manage this client's potentially violent behavior?Use clear, calm statements and set limits on the behavior.

A client comes to the emergency department reporting fever and severe upper left quadrant abdominal pain. The primary care provider suspects pancreatitis. Based on this information, the nurse expects to see an elevation in the client's serum amylase and lipase.

A client comes to the emergency department with deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PCO2 40, and HCO3- 18. The nurse reports to the provider that the client is experiencing metabolic acidosis.

A client diagnosed with acute systemic lupus erythematosus (SLE) is to begin treatment for systemic manifestations.The nurse should recognize that the preferred classification of medications to be used is corticosteroids.

A client diagnosed with multidrug resistant tuberculosis (MDR TB) has been prescribed ethambutol (Myambutol). The nurse plans to instruct the client that it is likely he will experience loss of red/green color discrimination.

A client has pseudomembranous colitis caused by clostridium difficile. The priority nursing intervention for this client is performing hand hygiene before and after contact with the client.

A client is admitted with a suspected diagnosis of tuberculosis. Which nursing action is of highest priority?Place the client on airborne isolation.

A client is in the dayroom when another client asks if two items of clothing match. The client with schizophrenia replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world if you let Him. Let your light shine in." Which of the following is the client demonstrating?Loose association A client is scheduled to have an electroencephalogram (EEG) in the morning. While preparing the client for the EEG, it is appropriate for the nurse to tell the client which of the following?"You need to shampoo your hair tonight, and don't put any styling products on it afterwards."

A client receiving chemotherapy has developed neutropenia. Which statement by the client indicates to the nurse that the client needs further instructions?"I'm planning a large gathering of friends and family for the holidays."

A client recently received a Mantoux skin test. After 48 hr , the test was evaluated by the nurse and reveals 10 mm of induration with slight redness. This indicates to the nurse that the client has been exposed to tuberculosis (TB).

Clients on neuroleptic antipsychotic medications are at a higher risk for developing agranulocytosis. What client data should the nurse review for the earliest indication of this problem?Temperature

A client's provider informs the nurse that the client's abdominal aortic aneurysm (AAA) is extending. The nurse must assess the client for abdominal pain with the onset of back pain.

A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood pressure at regular intervals.

A client who is regularly exposed to sunlight comes to the clinic to have several skin lesions evaluated. Which assessment finding should alert the nurse to the possibility of malignant melanoma?An irregularly shaped brown lesion with light blue areas on the neck

A client with Addison's disease comes to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse anticipates that the provider will prescribe IV administration of.corticosteroids.

A client with a history of chronic renal failure (CRF) has routine laboratory tests done with the following results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and albumin 3.0 g/dL. Which result should the nurse report to the client's primary care provider immediately?Hyperkalemia

A client with an acute visual disturbance describes it as a "curtain" pulled over the visual area with occasional flashes of light. The nurse should notify the provider immediately of the possibility of a detached retina.

A client with extensive deep partial and full thickness burns has been prescribed a topical antimicrobial drug. The nurse understands that the goal of this therapy is to reduce bacterial growth.

A clinic nurse is assessing a 66 year old client a for a routine physical. The client is new to the area and does not have old medical or immunization records available. When the nurse asks if the client has received the pneumococcal vaccine, the client replies, "I am not sure but I haven't had any immunizations in at least 5 years." The nurse should recognize that in this circumstance the client should receive the pneumococcal vaccine.

A clinic nurse is caring for an older adult client with an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse explains that whistling in hearing aids is often caused by excessive wax in the ear canal.

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A community health nurse is conducting a class on body mechanics for county office workers. Which of the following should the nurse include in the teaching? (Select all that apply.) "Sit with your back supported." "Knees should be at the hip level." "Wrist and forearms should be parallel to the ground."

A disabled client is taking phenelzine (Nardil) for depression. The nurse is teaching the client's new home health aide about the client's diet restrictions due to the medication. The nurse evaluates that the teaching has been effective when the home health aid selects which of the following for the client's lunch?Chicken salad and carrot sticks

The disaster plan for a hospital has been initiated following a community flood. Which of the following actions is the responsibility of the nurse during the disaster?Identify the stable clients in the intensive care unit (ICU) who can be transferred to the medical-surgical floor.

During a change of shift, a nurse is reviewing the medication administration records (MAR) for her assigned clients.The nurse notes that a prescribed dose of a medication is above the recommended safe range, and the dose was administered on the previous shift by a nurse. Which of the following actions should the nurse take?Call the prescriber to get the dose clarified.

During a client care unit meeting, the nurse manager discusses potential problems with data security related to confidential client information. The nurse manager explains that safe, effective environments where client information may be discussed include areas closed off from the public.

During preoperative teaching for a client scheduled for laser assisted in situ keratomileusis (LASIK) surgery, the nurse should tell the client that he may need to wear reading glasses after the surgery.

A family member of a client receiving hospice services asks the hospice nurse for assistance. The family member states that the client has insomnia almost nightly. The nurse assesses the client and documents the following: "Vital signs are stable, takes a short nap once a day as needed, walks around the neighborhood once a day if feeling ok, likes to watch television (TV) in bed during the day, goes to bed at 10 pm every night, drinks hot herbal tea before going to bed, and gets up to go to the bathroom once during the night." Which of the following mostly likely contributes to the client's insomnia?The client watches TV in the bed during the day.

A female client with a history of recurrent cystitis asks the nurse about preventing future episodes. Which client statement describes a self care activity that the nurse should discourage?"I prefer tub baths to showering."

A high carbohydrate, low protein diet is prescribed for a client who has chronic renal failure. The nurse explains to the client that the carbohydrates in this diet will help prevent ketosis.

A hospital receives a bomb threat and the charge nurse has to coordinate the evacuation of the clients. Which of the following actions should the nurse take when implementing the evacuation process?Instruct clients who are able to ambulate to leave.

An individual wearing a hospital-issued identification badge greets the charge nurse on the postsurgical unit and states, "I am a surgical resident assigned to this unit." The individual then asks the charge nurse for an access code to review a client's online record stating, "I'm not scheduled to attend the computer class until next week." Which of the following actions should the nurse take?Explain that it is against policy to share access codes and refer the resident to his supervisor.

In planning care for a child with severe reactive airway disease, the nurse knows that when chronic steroid use is indicated, inhaled steroids are preferred over oral steroids for which of the following reasons?Oral steroids can slow linear growth in children.

A newly licensed nurse is caring for a child who is brought to the emergency department with bruises that the nurse believes are due to child abuse. What should be the nurse's action at this time?Notify the charge nurse.

A nurse admits an child with a urinary tract infection (UTI) who has a history of myelomeningocele. After completion of