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NCLEX Fundamentals: Safety and In...
36 terms bennbrookePreview Uworld 13 terms Eliz A nurse is talking with the parent of a 6-year-old regarding sleep and rest. Which information should be included?
- Active play before bedtime promotes restful sleep
- Bedtime hours should be established
- Rest needs are related to the high rate of growth in this age group
- 7-8 hours of sleep are required
- Desensitization to a specific stimulus or situation
- Discussing the interpersonal difficulties that have led to the client's
- Helping the client to develop insight into the psychological causes of the
- Relaxation techniques
- Self-observation and monitoring
- Teaching new coping skills and techniques to reframe thinking
B A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? SATA
psychological problems
disorder
1,4,5,6
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? SATA
- Assist maternal pushing efforts by applying fundal pressuring during each
- Document the time the fetal head was born
- Flex the client's legs back against the abdomen and apply downward pressure
- Prepare for a forceps-assisted birth
- Request additional assistance from other nurses immediately
- Difficult to arouse
- Muscle stiffness
- Pinpoint pupils
- Temperature 94F (34.4 C)
- Client 1 day post coli resection who is receiving continual epidural morphine
- Client admitted 2 hrs ago with gastroenteritis who has been vomiting for 36 hrs
- Client who has received IV bumetanide for 3 days for heart failure and
- Client with acute poststreptococcal glomerulonephritis who is receiving
- Ask the client how ling the leg has been tender and warm
- Assess the ECG for any ectopic beats
- Check vital signs including pulse oximetry
- Complete neuromuscular assessment on the lower extremities
contraction
above the symphysis pubis
2,3,5 Upon arrival in the post-anesthesia care unit, the. nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the n nurse to notify the health care provider immediately
2 The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first
and reports severe itching
and has muscle cramps and weakness
experiences dizziness when standing up
antibiotics and has gross hematuria 2 A 62-year-old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago.The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority?
4
The client nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis?
- Anal itching that is worse at night
- Intestinal bleeding with anemia
- Poor appetite with weight loss
- Red, scaly, blistered signs on skin
- I'll be sure to apply sunscreen if I go outside
- I'll drink at least 8 glasses of water a day
- I'll drink decaffeinated coffee so I can sleep at night
- I'll sit on the side of my bed for a few minutes before getting up
- I'll take my medicine with food
- I am glad that I can continue to take my kava supplement each morning
- If i can't sleep, I will take some melatonin with my evening dose of clonazepam
- If I feel restless, I can put some drops of lavender essential oil in a diffuser to
- When my anxiety is getting really intense, I will drink some valerian tea to help
- Elevating the HOB 30-45 degrees
- Performing hourly in-line endotracheal suctioning
- Practicing strict hand hygiene
- Providing frequent oral care with chlorhexidine
- Scheduling daily sedation vacations
1 An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? SATA
2,4,5 The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
calm myself
me relax 3 A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? SATA
1,3,4,5
A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation?
- Drink 2 extra glasses of water with each meal
- Exercise for longer periods
- Include more fiber in the diet
- Take warm baths to relax the abdomen
- Client has cellulitis from injecting heroin; threatening to leave against medical
- Client is 1 day postoperative colectomy; night nurse medicated client with
- Client is 2 days postoperative open gastric bypass surgery; now reporting
- client is 3 days postoperative total knee replacement; waiting to be discharged
- Continue teaching the client and verify understanding by return demonstration
- Discuss how important it is for the client to pay attention during the teaching
- Maintain eye contract during the teaching by following the client's movements
- Provide written instructions and a private place for the client to learn
- Excess blinking of eyes
- Dry mouth
- Dull headache
- Lip smacking
- Puffing of cheeks
3 Which client does the nurse assess first after receiving the morning report?
advice if more morphine is not given right now
morphine 15 mins. ago
nausea and dry heaving
3 The nurse is teaching a client of America Indian heritage how to self-administer insulin. As the nurse described the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation?
independently 1 A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? SATA
1,4,5