BoardVitals NCLEX Prep

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22 terms AloidnemPreview ATI Dynamic Quizzes On Medical Su...52 terms JamNJuzPreview Board v 88 terms Vet A nurse is caring for a client who is in labor and has HIV.Which of the following procedures should the nurse identify as being safe for this client? (Select all that apply.)

• Vacuum extraction
• Oxytocin infusion
• Use of forceps
• Cesarean birth
• Internal fetal monitoring

B, D

Explanation:

Oxytocin infusion is a noninvasive procedure that is considered safe for this client because there is a little risk for maternal blood exposure to the fetus. Cesarean birth can be recommended for clients who have HIV, depending on their viral load, to reduce the risk for transmission of HIV to the fetus.A nursing student is learning about culturally competent care. They have learned that some groups do not value direct eye contact with the nurse or other healthcare providers. Which of the following cultural groups would most likely perceive direct eye contact negatively?(Select all that apply)

• Americans
• Asians
• Canadians
• Arabs
• Native Americans

B, D, E

The practical nurse is working with a client at risk for falls.The Nurse knows that all of the following people should

know information about preventing falls for this client:

• Nurses
• Physicians
• Family/Visitors
• Client
• All of the above

E A nurse is providing education to a client with a new prescription for furosemide (Lasix). What is the primary reason the nurse will advise the client to take this medication in the morning?

• Prevent electrolyte imbalance
• Slow drug absorption
• Excrete excess fluids accumulated during the night
• Prevent sleep disturbances during the night

D A nurse is providing teaching to a client who follows a vegetarian diet and is concerned about getting enough protein intake. The nurse should recommend which of the following foods as containing the greatest amount of dietary protein?

• Medium baked potato
• Homemade vegetable soup
• Black eyed peas and rise
• Canned fruit salad

C A 9 month old child weighs 20 lbs and has sustained a fracture of the right femur. The client is admitted and placed in Bryant's traction. The nurse knows that this type

of traction is:

• Continuous, skeletal
• Continuous, skin
• Intermittent, skeletal
• Intermittent, skin

B A nurse has the following tasks to complete. Which task can be appropriately assigned to a certified nursing assistant?

• Obtain routine vital signs on a group of clients
• Administer a tube feeding for a client with a

nasogastric tube

• Monitor the blood pressure of a client who is in

congestive heart failure

• Complete wound care for a client with burns

A

A nurse is taking care of a 77 year old client with electrolyte imbalances. The nurse assesses the client for the presence of the Chvostek sign. Which electrolyte imbalance would cause a positive Chvostek sign?

• Hypokalemia
• Hypocalcemia
• Hyponatremia
• Hyperglycemia

B A nurse is preparing to administer an oral medication to a client. The client states, "The pill I normally take is round. I don't think that is my medication." Which of the following responses should the nurse make?

• "Sometimes the same pill comes in different shapes."
• "I will see if this medication comes in a liquid form."
• "I will recheck the medication prescription in your

medical record."

• "This is the medication that your doctor wants you to

take." C A client is admitted with a suspected subarachnoid bleed and will undergo a diagnostic procedure. Choose the tasks for which the nurse is responsible while assisting with this procedure. (Select all the apply.)

• Inject the local numbing medication
• Assist the client in maintaining the correct position
• Open and set up the lumbar puncture tray
• Monitor the client's blood pressure and pulse
• Measure the pressure of the cerebrospinal fluid

B, D

All of the following are age related skin changes EXCEPT:

• Hair loss
• Wrinkles
• Xerosis
• Dark red color of the extremities

D Explanation: As an individual ages, hair loss, wrinkles, and xerosis (skin dryness) are all expected changes. A dark red color in the extremities, particularly the legs, may indicate that the client has problems with venous return.A nurse is caring for a 35 year old client who has had transsphenoidal surgery. The nurse understands that this surgery is generally done to correct an underlying dysfunction of which gland?

• Adrenal gland
• Pituitary gland
• Thyroid gland
• Pancreas

B

Explanation: Transsphenoidal surgery is a surgical approach to operate on the

pituitary gland via the sphenoid sinuses.

The client is receiving Clopidogrel following a cardiac stent placement. The nurse should ensure that the client understands which of the following? (Select all that apply.)

• Headache is a common side effect of the medication
• Clopidogrel can be stopped if symptoms become

annoying

• Bleeding and bruising are likely to increase with the

drug

• Clopidogrel can be taken with or without food

A, C, D

A client returned after transurethral resection of prostate and is on continuous bladder irrigation. He tells the nurse that he feels the need to void. The most appropriate

nursing action is:

• Remove the catheter
• Increase the flow of irrigating solution
• Notify the physician
• Manually irrigate the catheter

D Explanation: Manual irrigation with a syringe will help ensure the catheter is not clotted or clogged. If there is a blockage this should help remove it and alleviate the urge to void.A nurse is caring for a 70 year old client in a rehabilitation facility who has just had a stroke. The nurse recognizes that the client is having difficulty swallowing. The nurse knows that which of the following areas of the brain regulates the ability to swallow?

• Temporal lobe
• Medulla oblongata
• Cerebellum
• Frontal lobe

B Explanation: Swallowing is a voluntary act regulated by the swallowing center in the medulla oblongata.A client at 28 weeks gestation has been admitted to the obstetric unit for preeclampsia. Her blood pressure has been ranging from 140s/100 to 160s/110s. She has 3+ proteinuria and generalized edema, and has been complaining of a headache. Which care environment would be most appropriate for this client?

• Semiprivate room, up ad lib, vital sign every shift with

fetal heart tones, 2Gm sodium diet.

• Private room, bedrest with bathroom privileges, vital

signs with fetal heart tones every 4 hours, regular diet

• Three bed ward, ambulate 3 times a day, vital signs 2

times a day with fetal heart tones, low protein diet

• Labor room, strip t bedrest, vital signs every 15 minutes

with continuous fetal heart monitoring, nothing by mouth.B Explanation: Loud noises and bright lights can trigger seizures is a preeclamptic client; these stimuli can be minimized in a private room. The client needs to rest as much as possible and avoid stress. There are no dietary restrictions for a client with PIH or preeclampsia.