NCLEX PN REVIEW Adult Health

NCLEX PN REVIEW Adult Health ScienceMedicineNursing Sabiana_BeauchardTop creator on Quizlet Save Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview

NCLEX-PN

50 terms Amanda_Hunter36 Preview Adult Health final (NCLEX questions...103 terms miggyt1996Preview Renal/ 25 terms Mo A nurse is reinforcing instructions regarding home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed?

• Exposure to sunlight will worsen my psoriasis
• I should avoid drinking alcohol
• I should avoid scratching lesions
• Stress can worsen psoriasis
• Exposure to sunlight can worsen psoriasis

Rationale:

Psoriasis is a chronic, autoimmune condition characterized by exacerbations of silver plaques on reddened skin. Although there is no cure, management includes topical and systemic medications, phototherapy, and avoidance of triggers.A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?

• PaO2 49 mm Hg (6.5 kPa), PaCO2 6-mm Hg (8.0 kPa)
• PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
• PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
• PaOz 86 mm Hg (11.5 kPa) PaCO2 25mm Hg (3.33 KPa)
• PaO2 49 mm Hg (6.5 kPa) PaCO2 60 mm Hg (8.0 kPa)

Rationale Acute respiratory failure (ARF) is defined as inadequate gas exchange that results from too much carbon dioxide or inadequate oxygen. ARF may be intrapulmonary (eg, pneumonia, pulmonary embolism) or extrapulmonary (eg, head injury, opioid overdose) in origin. ARF is a potential complication of oversedation or following major surgical procedures, especially those involving the thorax and abdomen that may result in injury to the lung ABG values that indicate the presence of ARF are decreased PaO2 ≤60 mm Hg (8.0 kPa)

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further?

• I am having problems extending my fingers since this morning
• I cant take any of the pain medicine because it makes me feel sick
• I have to scratch under the cast with a nail file because of the itching
• I noticed a warm spot on my cast and a bad smell is coming from it
• I am having problems extending my fingers since this morning

Rationale:

Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers.Volkmann contracture occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply.

• Call for help
• Hold down clients arms
• Insert a tounge depresser to move the tounge
• Prepare for suctioning
• Turn the client on the side

Back Front 1.Call for help

• Prepare for suctioning
• Turn the client to the side

Rationale:

During an active seizure, the nurse should call for additional help, turn the client on the side if possible, and have suction equipment ready to clear any excessive secretions that may block the airway. The nurse should not restrain the client or force anything into the client's mouth.* The client should not be restrained as this could cause an injury (Option 2). Oral airways should be kept at the bedside for postictal airway management and recovery, but during an active seizure it is dangerous to attempt to insert anything in the client's mouth, especially if the teeth are clenched (Option 3).An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms?

• Brain natriuretic peptide 70 pg/ml
• Hematocit 21%
• Leukocytes 3,500/mm^3
• Platelets 105,000/mm^3
• Hematocrit 21%

Rationale:

Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply.

• Oral bite prevention device
• Oxygen delivery system
• Padding on the bed side rails
• Soft arm and leg restraints
• Suction equipment
• Oxygen delivery system
• Padding on the bed side rails
• Suction equipment

Rationale:

Turning the client on the side, providing oxygen and suctioning as needed, and padding the side rails or removing objects that are near the client can decrease the risk for injury during a seizure. Restraints should not be used. Nothing should be placed in mouth during seizure.The nurse is assisting with the care of an adolescent diagnosed with type 1 diabetes. The client has hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been ordered. Cardiac monitoring reveals a sinus rhythm with peaked T waves, and the client has minimal urine output. What does the nurse anticipate as the next priority action?

• Administer IV regular insulin
• Administer normal saline infusion
• Obtain client's urine for urinalysis
• Request a potassium infusion prescription
• Administer normal saline infusion

Rationale:

This client has diabetic ketoacidosis, and all clients with this condition experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is a normal saline (0.9%) infusion

• next insulin and be administered and potassium can be given once levels are normal and low

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?

• Genital Herpes and HIV
• Gonorrhea and chlamydia
• Human papillomavirus and syphilis
• yeast and trichomoniasis
• Gonorrhea and chlamydia

Rationale:

Gonorrhea and chlamydia are the most common causes of pelvic inflammatory disease, which can lead to infertility. Therefore, annual gonorrhea and chlamydia screening is recommended for all sexually active females age <25 and older females with risk factors.

The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply.

• African Americans
• Diabetes mellitus type 2
• Frequent stress at work
• LDL OF 94 mg/dl
• Smoking of 1 pack of cigarettes daily
• African American ethnicity
• Diabetes mellitus type 2
• Frequent stress at work
• Smoking of 1 pack of cigarettes daily

Rationale:

Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure.clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]).The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority?

• Ask the UAP to stop compressions and check for a pulse
• Establish additional IV access with large-bore IVs
• Obtain the defibrillator and apply the pads to the client's chest
• Prepare to administer 100% O2 with a bag valve mask
• Obtain the defibrillator and apply the pads to the clients chest

Rationale:

For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?

• 25 year old client who reports a fish like vaginal odor for the past month
• 30 year old client with an intrauterine device who reports heavy bleeding with menses
• 40 year old client with endometriosis who reports persistent pain during intercourse
• 60 year old client who reports bloating and pelvic pressure for the past two months
• 60 year old client who reports bloating and pelvic pressure for the past two months

Rationale:

Symptoms of ovarian cancer are often subtle, and the condition is often not discovered until an advanced stage due to a lack of routine screening guidelines. Clients may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.