Online NCLEX Practice Test about
1. An 88-year-old client is complaining of severe constipation. The nurse assists the client to the bathroom and administers a mineral oil enema. Two minutes later, the client rings the call bell. The nurse arrives to find the client on the floor with a weak, thread pulse of 35 beats per minute. The most likely explanation for the client’s condition is:
a. Myocardial ischemia
b. Pulmonary embolus
c. Improper administration of enema
d. Vasovagal response
2. A client with a casted comminuted fracture of the tibia is having difficulty breathing. Which is the best immediate nursing intervention for this client?
a. Obtain an arterial blood gas (ABG)
b. Reposition the client’s casted arm above the level of the heart
c. Administer oxygen by facial mask
d. Monitor vital signs every 15 minutes, especially respirations
3. In general, the adaptations most frequently experienced by a woman with any of the common sexually transmitted disease include:
a. Discharge and dysuria
b. Rash and lesions
c. Dysmenorrhea and menorrhagia
d. Pain and leukorrhea
4. A client with hyperpyrexia who has just been started on IV antibiotics has a diminished urine output. The nurse should recognize that this probably the result of:
a. A declining blood pressure
b. Bacterial invasion of the kidneys
c. Nephrotoxicity from antimicrobial agents
d. A normal compensatory response to fever
5. A client has been receiving 2500 ml of IV fluid and 300 to 800 ml of oral intake daily for 2 days. The client’s urine output has been decreasing and now has been less than 4o ml per hour for the past 3 hours. The nurse should initially:
a. Catheterize the client to empty the bladder
b. Assess breath sounds and obtain the client’s vital signs
c. Check for dependent edema and continue to monitor I & O
d. Decrease the IV flow rate and increase oral fluids to compensate
6. A client appears very anxious, with 40 shallow breaths per minute. The client complains of feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client’s complaints are probably related to:
c. Kussmaul’s respirations
d. Carbon dioxide intoxication
7. During the last 48 hours, a client has been receiving fluid restriction for his major burn. Which assessment indicates proper rehydration in the client?
a. BP 95/60 mm Hg, respiratory rate of 32 per minute
b. Urine output greater than 35 cc per hour
c. Urine specific gravity greater than 1.030
d. BP 100/55 mmHg, heart rate of 105 per minutes
8. A client is brought to the emergency department with burns on the chest, neck and head. On which of the following assessments should the nurse place the highest priority of care?
a. Airway patency
b. Fluid volume replacement
c. Degree of pain
d. Extent of the injury
9. Which statement by the client indicates that the discharge instruction about activity restrictions post cataract surgery of the right eye has been effective?
a. “I can continue sketching my tulips in the garden.”
b. “I will be able to take my daily shower.”
c. “I can now resume air travel.”
d. “I will be able to resume my job as a furniture mover.”
10. A client is hospitalized with an acute sinus infection. Which of the following assessments made by the nurse indicates serious complications?
a. Orbital edema
b. Nuchal rigidity
c. Fever of 102 F (39c)
d. Frontal headache
11. A client has driven himself into the emergency room. He is 52-years-old, has a history of hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2L/minute per nasal cannula. The nurse’s next action would be to:
a. Call for a doctor
b. Start an IV line
c. Obtain a portable chest radiograph
d. Draw blood for laboratory studies
12. A 67-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness. The first nursing action would be to:
a. Inquire about the onset, duration, severity and precipitating factors of heaviness
b. Administer oxygen via nasal cannula
c. Offer pain medication for the chest heaviness
d. Inform the physician of the chest heaviness
13. In which of the following positions should the nurse place a client with suspected heart failure?
a. Semi-sitting (low Fowler’s position)
b. Lying on the right side (Sims’ position
c. Sitting almost upright (high Fowler’s position)
d. Lying on the back with the head lowered (Trendelenburg position)
14. The nurse is admitting a 70-year-old man to the clinical unit. The client has a history of left ventricular enlargement. During the assessment, the nurse notes +3 pitting edema of the ankles bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at rest. The nurse infers that the client may have:
b. Congestive heart failure
c. Chronic bronchitis
d. Acute myocardial infarction
15. The nurse understands that a priority nursing diagnosis for the client with hypertension would be:
b. Deficient fluid volume
c. Impaired skin integrity
d. Ineffective health maintenance
16. Which of the following should the nurse teach the client with unstable angina to report immediately to her physician?
a. A change in the pattern of her pain
b. Pain during sexual activity
c. Pain during an argument with her husband
d. Pain during or after an activity such as lawn mowing
17. Which of the following is the most important aspects of pain management for the client after a thoracotomy?
a. Repositioning the client immediately after administering pain medication
b. Reassessing the client 30 minutes after administering pain medication
c. Verbally reassuring the client after administering pain medication
d. Readjusting the pain medication dosage as needed according to the client’s condition
18. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
a. Administering oxygen every 2 hours
b. Turning the client every 4 hours
c. Administering sedatives to promote rest
d. Suctioning if cough is ineffective
19. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:
a. The effects of thyroid hormone replacement therapy and will diminish over time
b. Related to the thyroid hormone replacement and will not diminish over time
c. A normal part of having a chronic illness
d. Most likely related to low thyroid hormone levels and will improve with treatment
20. A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy?
a. Removing the source of excess hormone should restore the client’s libido, erectile function and fertility
b. Potency will be restored but the client will remain infertile
c. Fertility will be restored but impotence and decreased libido will persist
d. Exogenous hormones will be needed to restore erectile function after the Adenoma is removed
21. Which of the following symptoms are considered signs of fracture?
a. Tingling, coolness, loss of pulses
b. Loss of sensation, redness, warmth
c. Coolness, redness new site of pain
d. Redness, warmth, pain at he site of injury
22. Which of the following nursing measures would be used to treat pulmonary edema?
a. Antibiotics, oxygen and digoxin
b. Oxygen, diuretics and high-Fowler’s position
c. Oxygen, morphine sulfate and supine position
d. Nitroglycerin, steroids and oxygen therapy
23. An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). In addition to routine suctioning of the tracheotomy, the nurse should also suction the toddler:
a. becomes diaphoretic and cyanotic
b. has severe substernal retractions and stridor
c. Verbalizes an increased difficulty in breathing
d. becomes restless or pale or has an increased pulse rate
24. A client with a history of cardiac problems complains of severe chest pain. What should be the nurse’s initial response?
a. Notify the physician
b. Administer an analgesic to control pain
c. Assess the client’s pain
d. Start oxygen at 2 L/minute via nasal cannula
25. A client with extensive burns has n new donor site. Which of the following considerations is important in positioning the client?
a. Make the site dependent
b. Avoid pressure on the site
c. Keep the site fully covered
d. Allow ventilation of the site
26. A client with a pulmonary embolism is discharged but will remain on warfarin (Coumadin) therapy for up to 6 months to accomplish which of the following actions?
a. Prevent further embolism formation
b. Minimize the growth of new or existing thrombi
c. Continue to reduce the size of the pulmonary embolism
d. Break up the existing pulmonary embolism until it is totally gone
27. An elderly client has a wound that isn’t healing normally. Interventions should be based on which of the following principles or test results?
a. Laboratory test results
b. Kidney function test results
c. Poor wound healing expected as part of the aging process
d. Diminished immune function interfering with ability to fight infection
28. The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow up care. Which of the following would be the most effective method of follow up?
a. Daily phone calls from the hospital nurse
b. Enrollment in community parenting classes
c. Twice-weekly clinic appointments
d. Weekly visits by a community health nurse
29. The parents of a child just diagnosed with juvenile rheumatoid arthritis (JRA) tell the nurse that the diagnosis frightens them because they know nothing about the prognosis. Which of the following would the nurse include when teaching the parents about the disease?
a. Half of affected children recover without joint deformity
b. Many affected children go into long remissions but have severe deformities
c. The disease usually progresses to crippling rheumatoid arthritis
d. Most affected children recover completely within few years
30. During the initial assessment of a child to the pediatric unit with osteomyelitis of the left tibia, the nurse would expect the area over the tibia to exhibit which of the following?
a. Diffuse tenderness
b. Decreased pain
c. Increase warmth
d. Localized edema
31. A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important?
c. Excessive bleeding
d. Rectal fistulas
32. The nurse observes cardiopulmonary resuscitation (CPR) being performed on an 8-month-old patient. The nurse should intervene if:
a. The patient’s neck is hyperextended
b. The depth of chest compression is ½ to 1 inch
c. The patient’s nose and mouth are covered by the rescuer’s mouth
d. The rate of chest compression is 100 per minute
33. A mother calls the pediatric clinic and tells the nurse that she thinks her 18-month-old daughter has croup. The nurse would be most concerned if the mother made which of the following statements?
a. “My daughter is restless and I can see her ribs when she breathes.”
b. “My daughter’s temperature is 101.1 F (38.3 C) and she sounds hoarse.”
c. "My daughter cries and has a “barking” cough”
d. “My daughter refuses to eat breakfast and is irritable.”
34. Chest x-rays reveal a right-sided pneumothorax for a 28-year-old man. The nurse would expect to hear:
a. Reduction of breath sounds on the right side
b. Bilateral reduction in breath sounds
c. Crackles and wheezes on inspiration bilaterally
d. High-pitched expiratory wheezes on the right-side
35. A 21-year-old is brought to the emergency room after an automobile accident. The nurse notes that the patient’s abdomen in distended and rigid with an area of ecchymosis around the umbilicus. Which of the following orders should the nurse implement first?
a. Check the abdomen
b. Insert a #19 Foley catheter
c. Start an IV in the right arm with a 19 gauge needle
d. Obtain a urine sample for analysis
36. The nurse finds a 5-year-old boy having a grand mal seizure. What action should the nurse take first?
a. Call for help
b. Place a padded tongue blade between his teeth
c. Place a pillow under his head
d. Straddle his legs and holds his arms
37. A client is seen in the prenatal clinic. During the third trimester of pregnancy, the hemoglobin is 13.0 g/dl and the hematocrit is 34%. The nurse explains to this client that the decrease in the hematocrit is related to:
a. Decrease of fluid in the intravascular space
b. The physiologic anemia or pseudoanemia of pregnancy
c. Poor dietary intake of iron-rich foods
d. Decreased cardiac output
38. A client is seen in an ambulatory clinic who has a diagnosis of cirrhosis of the liver. When assessing this client, the nurse understands the most important monitoring should be:
a. Auscultation of breath sounds
b. Neurological checks
c. Abdominal palpation
d. Inspection of the skin
39. A mother asks what causes her child who has cystic fibrosis to be so sick. The nurse explains that the primary pathophysiologic mechanism in cystic fibrosis is:
a. Respiratory failure and weakness
b. An inability to metabolize sodium
c. Malabsorption of nutrients
d. Viscous mucous obstructing organs
40. A 22-year-old quadriplegic, admitted to the hospital for treatment of a pressure ulcer, complains of a pounding headache. The nurse assesses a blood pressure of 202/106 mmHg, pulse 115 bpm, and respirations of 28/minute and shallow. The nurse would implement which action initially?
a. Place the client in Trendelenburg position
b. Administer oxygen by nasal cannula at 4 L
c. Administer morphine sulfate 2 mg IV push
d. Sit the client up with feet hanging down
41. A 9-year-old child, who has a past history of acute rheumatic fever, is admitted for treatment of a streptococcal infection. The nurse would monitor the client for which assessment finding?
a. Auscultation of a systolic murmur
b. Increasing urinary output
c. Increasing joint pain
d. Presence of subcutaneous nodules
42. The membranes of a woman in labor rupture spontaneously. An observation by the nurse at this time that would necessitate additional newborn resuscitation measures would be:
a. Bloody show
b. Greenish fluid
c. Clear fluid with specks of mucus
d. shortened intervals between contractions
43. The nursing care plan for a client who is being admitted to the hospital with a diagnosis of abruptio placenta should include careful assessment for signs and symptoms of;
c. Hypovolemic shock
d. Impending convulsions
44. The primary goal of therapy for a client with chronic obstructive pulmonary disease is to:
a. Limit hydration
b. Improve ventilation
c. Increase oxygenation
d. Correct the bicarbonate deficit
45. The adaptation in a child with nephrotic syndrome that would necessitate that the nurse check vital signs, especially the pulse quality, rate and blood pressure is:
c. Pulmonary emboli
d. Congestive heart failure
46. When caring for a child in acute respiratory distress syndrome from laryngotracheobronchitis, who has a temperature of 103 F, the nurse should give priority to:
a. Delivering 40% humidified oxygen
b. Initiating measures to reduce fever
c. Constantly assessing the child’s respiratory status
d. Providing support to reduce the child’s apprehension
47. A client who was in an automobile accident is brought to the emergency room via ambulance. Which finding should alert the nurse that a client may be developing hypovolemic shock due to massive trauma?
a. Urinary output of 80 ml/hr
b. Hemoglobin 10 g/dl and hematocrit of 33%
c. Central venous pressure (CVP) below 1.0 mm H20
d. 2+ edema of the extremities
48. A nine-year-old child with hemophilia cut his hand while working on a craft project in the hospital play room. The initial nursing action to take is:
a. Apply pressure to the bleeding area for at least 10 to 15 minutes
b. Apply an ice pack
c. Cover the wound with a sterile dressing
d. Notify the physician immediately
49. A child who is two years and six months old has had one bout of nephrosis (nephritic syndrome). His mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm this condition by recognizing what additional symptom?
a. Blood pressure 140/90
b. Marked Proteinuria
c. Cola-colored urine
d. A history of positive streptococcal infection
50. A client with history of COPD develops a pneumothorax, and a chest tube is inserted. The primary purpose of the chest is which of the following?
a. Lessen the client’s chest pain and discomfort
b. Drain accumulated fluid from the pleural cavity
c. Restore negative pressure in the pleural space
d. Prevent subcutaneous emphysema in the chest wall
51. The nurse is aware that one reason the dialysate used in peritoneal dialysis is warmed to body temperature before its instillation into the peritoneal cavity is to:
a. Force potassium back into the cells, thereby decreasing serum levels
b. Encourage removal of serum urea by dilating the peritoneal blood vessels
c. Add extra warmth to the body because metabolic processes are disturbed
d. Help prevent cardiac dysrhythmias by speeding removal of excess serum potassium
52. After exposure to a nephrotoxic substance, a client is hospitalized in the oliguric phase of acute renal failure. The client’s estimated urine output for the last 24 hours is about 2 cups. The BUN level is 96 mg/dl. The physician orders 900 ml of water by mouth during the next 24 hours. In carrying out this order, the nurse realizes that the rationale for the order is that 900 ml of fluid will:
a. Equal the expected urinary output for the next 24 hours
b. Prevent the development of complicating hypostatic pneumonia
c. Compensate for both insensible and measured fluid losses over the next 24 hours
d. Prevent hyperkalemia, which could result in the client having serious cardiac dysrhythmias
53. A client is at high risk for developing ascites. To assess for this condition the nurse should:
a. Observe for signs of respiratory distress
b. Percuss the abdomen, listening for dull sounds
c. Palpate the lower extremities over the tibia and observe for edema
d. Auscultate the abdomen, listening for decreased or absent bowel sounds
54. One day the mother of a 7-year-old, previously hospitalized with nephritic syndrome several months before, calls the clinic nurse. She reports that for the past week her child has had a muddy pale appearance, a poor appetite, and been unusually tired after school. The nurse suspects that the child:
a. Is not taking her medications
b. Is developing a viral infection
c. May be in impending renal failure
d. May be overextending herself at school
55. Nine months after vagotomy, a client is readmitted with complaints of projectile vomiting, weight loss, and anorexia. Because of the history of duodenal ulcers, the nurse knows that the client is at risk for
a. Gastric carcinoma
b. Small bowel obstruction
c. Gastric outlet obstruction
d. Hiatal hernia
56. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse would suspect atrial fibrillation when palpation of the radial pulse reveals:
a. Two regular beats followed by one irregular beat
b. An irregular pulse rhythm
c. Pulse rate below 60 bpm
d. A weak and thready pulse
57. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection?
a. The client maintains a fluid intake of 800 ml every 24 hours
b. The client experiences chills only once daily
c. The client coughs productively with chest discomfort
d. The client experiences less nasal obstruction and discharge
58. When performing postural drainage, which of the following factors promotes the movement of secretions form the lower to the upper respiratory tract?
a. Friction between the cilia
b. Force of gravity
c. Sweeping motion of cilia
d. Involuntary muscle contractions
59. A child was brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?
a. A prolonged inspiratory time and a short expiratory time
b. Frequent productive cough of clear, frothy, thin mucous progressing to thick, tenacious mucus heard only on auscultation
c. Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations
d. Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous
60. A 13-year-old client has received third-degree burns over 20% of his body. When performing an assessment at 72 hours after the burn, which of the following should the nurse expect to find?
a. Increasing urine output
b. Severe peripheral edema
c. Respiratory distress
d. Absent bowel sounds
61. A school-age child has a hydrocephalus and is admitted for a revision of his ventriculo-peritoneal shunt. When he returns from surgery, how should the nurse position him?
a. On his abdomen where he is comfortable
b. In semi Fowler’s position to prevent aspiration
c. With the bed flat to prevent a subdural hematoma
d. On the same side as the shunt repair
62. The nurse is caring for a child with spina bifida. Which of the following factors determines the extent of sensory and motor function loss in the lower limbs of the child?
a. Maternal age at conception
b. Degree of spinal cord abnormality
c. Uterine environmental factors such as cloudy amniotic fluid
d. Time frame from diagnosis to birth of the infant
63. Which of the following client histories is most consistent with the diagnosis of sudden infant death syndrome (SIDS)?
a. The child was physically abused in the past
b. The infant had a history of many medical problems
c. The infant was healthy and was found shortly after being out down to sleep
d. The infant was described as lethargic, irritable, and feeding poorly before being put down to sleep
64. A baby girl delivered at 38 weeks’ gestation weighs 2,325 grams (5 lb, 2 oz) and is having difficulty maintaining body temperature. Which of nursing intervention would best prevent cold stress?
a. Immediately after birth, dry the neonate and place her under a radiant warmer for 2 hours
b. Administer oxygen for the first 30 minutes after birth
c. Decrease integumentary stimulation after birth
d. Maintain the environmental temperature at a constant level
65. When caring for the preeclamptic client during labor, the nurse should:
a. Give a fluid bolus before the second stage
b. Give extra fluids throughout labor
c. Restrict the amount of fluid administered
d. Refrain from administering fluids during the labor
66. Which of these actions should be included in the care of a client who is having a generalized seizure?
a. Insert a tongue blade between the client’s clenched teeth
b. Restrain the client’s extremities
c. Determine if the client’s has been compliant with seizure precautions
d. Observe the sequence and characteristics of the seizure
67. An essential goal in the management of a client in the early stage of pancreatitis is to:
a. Maintain client’s fluid orders
b. Support client in high Fowler’s position
c. Provide the client with a high-caloric diet
d. Check the client for greasy stools
68. A newly diagnosed diabetic informs the nurse that she has not been eating to try and better control her blood sugar. The nurse tells her that this is not a solution to blood glucose control because blood glucose is regulated not only by insulin but by glucagons, which is stimulated to raise blood glucose when a person has not eaten. Glucagon causes a rise in glucose by stimulating:
a. Glycogen breakdown and release from the muscles
b. The intestine to absorb glucose
c. The liver to release glucose into the blood
d. The brain to release glucose
69. A 35-year-old man is receiving three different chemotherapeutic agents for Hodgkin’s disease. The nurse explains to the client that the three drugs are given over an extended period because:
a. The three drugs can be given at lower doses
b. The second and third drugs increase the effectiveness of the first drug
c. The first two drugs are toxic to cancer cells, and the third drug promotes cell growth
d. The three drugs have a synergistic effect and act on the cancer cells with different mechanisms
ANSWERS AND RATIONALE
- vasovagal response is an exaggerated parasympathetic response due to coughing, increased abdominal pressure (from constipation), or nausea and vomiting. This results in Bradycardia, hypotension, and diaphoresis. It responds to bed rest, Trendelenburg position, a fluid challenge and atropine administration. Vasovagal responses are usually self-limiting and not dangerous to the client unless injury results from the client’s fall.
- the objective of management for a possible pulmonary or fat embolism is to support the respiratory system. High concentrations of oxygen are given via face mask. The nurse would monitor the vital signs; however, the priority is to administer the oxygen.
- discharge and dysuria are the most commonly experienced adaptations in women with STDs. Most clients with an STD do not experience rash or lesions. Painful menses and heavy menstrual bleeding are not commonly associated with STDs. Most women with an STD are free of pain. Leukorrhea is a normal finding.
- pyrexia increases fluid loss through the skin; to maintain balance, the body compensates by reducing urinary output. BP is not directly affected by antimicrobials, and there are no data to suggest BP is decreasing.
- the imbalance is intake and output, with a decreasing urinary output, may indicate renal failure with an increase of body fluid and the resulting development of CHF; assessing breath sounds and vital signs are the first steps to monitor for these complications.
- the client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis. Eupnea is normal, quiet breathing. Kussmaul’s respirations are deep, gasping respirations associated with diabetic ketoacidosis and coma, not hyperventilation associated with anxiety.
- urine output is the most reliable indicator, with range of 30-50ml/hour in adults.
- burns involving the face, chest, and neck indicate burns or smoke inhalation. A patent airway is always the first priority. Use ABCs.
- activities should aim at not increasing intraocular pressure in the eye. Activities that require bending, that changes pressure and that require are restricted for periods of 2-6 weeks post surgery.
- Nuchal rigidity indicates neurologic involvement, possible meningitis. The other interventions are typical of a sinus infection.
- advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV lines.
- further assessments are needed in this situation. It is premature to initiate actions until further data have been gathered. Inquiring about the onset, duration, location and severity and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.
- sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows for maximum space for the lung expansion. Low Fowler’s position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg position
- peripheral edema is a symptom of CHF. CHF results when the heart chronically pumps against increased resistance or is unable to contract forcefully to pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there is an accumulation of volume within the closed system. The client’s symptoms do not indicate arteriosclerosis, chronic bronchitis or acute MI.
- managing hypertension is a priority for the client with hypertension. Clients with hypertension frequently do not experience other signs and symptoms, such as pain, deficient fluid volume, or impaired skin integrity. It is asymptomatic nature of hypertension that makes it difficult to treat, because clients may not recognize they are hypertensive or may not perceive the need for aggressive management of the disease.
- the client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.
- it is essential that the nurse evaluates the effects of pain medication after the medication has had time to act; reassessment is necessary to determine the effectiveness of pain management plan. Although it is prudent to check for discomfort related to positioning when assessing the client’ pain, repositioning the client immediately after giving pain medication is not necessary. Verbally assuring the client after giving pain medication may be useful to help instill confidence in the treatment plan. However, it is not as important as evaluating the effectiveness of the medication. Readjusting the pain medication dosage as needed according to the client’s condition is essential, but the effectiveness of the medication must be evaluated first.
- the nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions and not every 4 hours. Administering sedatives can depress respirations.
- hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking the serum thyroid hormone and TSH levels. This client needs to know that these feelings may be related to her low thyroid hormone level and may improve with treatment.
- the client’s sexual problems are directly related to the excessive prolactin level. Removing the source of excessive amount of hormone secretion should allow the client to return gradually to a normal physiologic pattern. Fertility will return to baseline as hormone levels return to normal.
– Signs of fracture may include redness, warmth and new site of pain. Coolness, tingling and loss of pulses are signs of vascular problem.
- Treatment for pulmonary edema involves placing the client in a high-Fowler’s position and administering oxygen.
- these are some of the first signs of hypoxia; the airway must be kept patent to promote oxygenation. Option 1 are late signs of hypoxia; suctioning should have been done well before this time. Option 2 are also late signs of respiratory difficulty. Option 3 the client will not be able to communicate verbally after a tracheotomy.
- the nurse’s first response is to further assess the client’s pain. After a thorough assessment, additional appropriate actions may be to notify the physician, administer an analgesic and administer oxygen.
- a universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices covered in some institution, but are not hallmarks of donor site. Placing the site in apposition of dependence isn’t justified aspect of donor site care.
- warfarin (Coumadin) minimizes the growth of new or existing thrombi. It’s impossible to tell whether a client who developed a thrombus that became a pulmonary embolism will develop more thrombi. Therefore, current therapy is to treat clients who had a pulmonary embolism with warfarin for up to 6 months, as long as it’s not contraindicated. Warfarin doesn’t reduce the size of existing pulmonary emboli or break them up.
- immune function is important in the healing process and diminished response may slow or prevent the healing process from taking place. Although immune function declines with age, there are healthy behaviors that will enhance the elderly’s individual response to tissue trauma (nutrition, exercise). Kidney function and laboratory results are important, but are not solely responsible for health outcomes.
- the most effective follow up care would occur in the home environment. The community health nurse can evaluate the infant’s progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.
- in half of the children with JRA, recovery occurs without joint deformity. Approximately, one third of the children will continue to have the disease into adulthood, and approximately one sixth will experience severe, crippling deformities.
- findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red.
- the client with a 3rd degree laceration should be assessed for constipation, because a 3rd degree laceration extends to a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fistulas may develop at a later time, but not at 48 hours postpartum.
- airway of infant is very small and flexible, hyperextension can actually close it off; if no neck injury is suspected, head is gently tilted back to neutral sleeping position.
- increasing restlessness, flaring nares, increased respiratory rate and intercostals retractions are early signs of impending airway obstruction.
- there will be diminished breath sounds because there is no air coming into collapsed lung. There will not be reduced sounds in the left lung; only the right lung is affected.
- blunt trauma results in bleeding and shock, so it is important to start an IV line.
- the nurse needs to protect the client from injury using padded side rails, airway at bedside pillow under head, loosen clothing and clear space
- both vascular volume and red cell productivity increase in pregnancy. However, there is a disproportionate increase in vascular volume when compared to red blood cell production; as a result the hematocrit drops. This decrease in hematocrit is referred to as the physiological (pseudoanemia) of pregnancy.
- neurologic checks are essential to determine changes in the client’s level of consciousness and mental functioning. Early detection of change will influence care and improve the client’s chances of recovery. Respiratory assessment is important, but it is not the cornerstone of cirrhosis assessment.
- excessive, thick secretions cause respiratory and digestive sequelae. Respiratory failure and weakness are features of the disease, not pathophysiologic mechanisms. Nutrient malabsorption is a feature of the disease.
- the client is demonstrating signs of autonomic dysreflexia. With spinal cord injury, the feedback between sympathetic and parasympathetic braches of the autonomic nervous system is disrupted (ANS). If the ANS is over-stimulated below the injury, an overproduction of sympathetic response occurs. The initial nursing action is to remove the potential cause and place the client in a position that will promote the orthostatic reduction of the blood pressure.
- tachycardia and cardiac murmur indicate cardiac involvement, which could be life threatening with recurrent rheumatic fever. The nurse would expect increasing joint pain with the recurrence of rheumatic fever, but this would not be the primary observation to be made.
- greenish fluid is indicative of meconium, which is released by the fetus; it is considered a possible indicator of fetal distress and potentially could be aspirated by the fetus.
- in abruptio placenta there is uterine bleeding that can result in massive internal hemorrhage, causing hypovolemic shock.
- improving ventilation provides comfort, maintains existing lung function, and prevents further lung damage. Some decrease in hypoxia will promote comfort, but the primary problem is too much carbon dioxide rather than too little oxygen.
- the shift of fluid predisposes the child to hypovolemia; an increased thready pulse and hypotension are signs of shock. CHF is a major complication of glomerulonephritis.
- laryngeal spasms can occur abruptly; patency of the airway is determined by constant assessment for symptoms of respiratory distress.
- the normal CVP is 4-10 cm H20; a markedly decreased reading indicates hypovolemia normal urinary output is 30-50 ml/hour. A hemoglobin of 10 gm/dl and a hematocrit of 33% do not indicate hypovolemia because these are near normal levels. Extremity edema indicates fluid overload and/or cardiac pump failure
- applying direct pressure allows for clot formation. A child with hemophilia will require 10 to 15 minutes for clot formation. Applying an ice pack will be beneficial for vasoconstriction. However, pressure is the initial action, not an ice pack. It is not necessary to notify the physician immediately unless the nurse is unable to control bleeding with pressure.
- in nephritic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls.
- negative pressure is exerted by gravity drainage or by suction through the closed system. In a pneumothorax associated with COPD, there is an accumulation of air, not fluid.
- heat promotes vasodilation, which aids the shift of urea, a large molecular substance, from blood vessels into the dialyzing solution. Excess serum potassium is removed by dialyzing with a potassium-free solution, not heat
- client’s measured urine output is about 500 ml in 24 hours based on the available history; insensible losses are 400 to 500 ml in 24 hours.
- percussing over fluid produces a dull sound, not the normal tympanic sound. Respiratory distress occurs with ascites but it is not an early sign. Bowel sounds do not indicate much about early ascites; when ascites is extensive, bowel sounds may diminish
- poor appetite and decreased energy are associated with an accumulation of toxic waste; associated anemia accounts for pallor.
- Gastric outlet obstruction may occur as a result of this surgery. Gastric carcinoma is not a complication of vagotomy or duodenal ulcer. Small bowel obstruction is not related to vagotomy, and does not result in the symptoms described in the question. Hiatal hernia manifests with indigestion, and is not related to the situation in the question
- characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note irregular rate and should report it to the physician. A weak and thready pulse is characteristic of a client in shock.
- a client is recovering from an upper respiratory tract infection should report decreasing or no nasal discharge or obstruction. Daily fluid intake should be increased to more than 1L every 24 hours to liquefy secretions. The temperature should be below 100F (37.8C) with no chills or diaphoresis. A productive cough with chest pain indicates pulmonary infection, not respiratory tract infection.
- the principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of the cilia is not sufficient to move secretions. Muscle contractions do not move secretions within the lungs.
- the wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
- during the resuscitative-emergent phase of a burn, fluid shifts back into the interstitial space resulting in the onset of diuresis. Edema resolves during the emergent phase, when fluid shifts back to intravascular space. Respiratory rate increases during the first hours as a result of edema. When edema resolves, respirations return to normal. Absent bowel sounds occur in the initial stage.
- the child should be kept flat to decrease complications that might occur from too rapid a reduction in intracranial fluid. When the fluid is drained too rapidly, a subdural hematoma may result. In children with increased ICP, the position of choice is with the head of the bed elevated and the child lying on the side opposite the shunt to keep pressure off the shunt valve.
- the extent of motor and sensory loss primarily depends on the degree of spinal cord abnormality. Secondarily, it depends on traction or stretch resulting from an abnormally tethered cord, trauma to exposed neural tissue during delivery, and postnatal damage resulting from drying or infection of the neural plate.
- Children who are diagnosed with SIDS are typically described as healthy with no previous medical problems. They are usually found dead after being put down to sleep. Depending on how long the infant has been dead, the infant may have a mottled complexion with extreme cyanosis of the lips, fingertips, or pooling in the legs and feet that may be mistaken for bruising.
- drying the neonate and placing her in a radiant warmer helps prevent loss of body heat. Administering oxygen and decreasing integumentary circulation would have no effect in preventing cold stress. Maintaining environmental temperature wouldn’t prevent loss of heat via conduction, evaporation or convection.
- the volume of fluids administered to the preeclamptic client should be restricted. Client usually receives between 60 and 150 ml/hr.
- characteristics of the seizure, such as how long it lasted, where it began and progressed to, whether incontinence or loss of consciousness occurred, and the type of movements, provide valuable diagnostic information.
- hypovolemia occurs from vast amounts of plasma released into the peritoneum and from repeated vomiting. The vomiting event would usually prevent intake of food. Greasy stools are not typical.
- when blood glucose drops, the pancreas secretes the hormone glucagons. The glucagon travels to the liver, where it stimulates the liver to release glucose. The muscle does not release glucose into the blood stream. Glucagon does not stimulate intestinal absorption of glucose. Glucagons works only at the liver.
- Multiple regimens are used because the drugs have synergistic effect. The drugs have different cell cycle lysis effects, different mechanisms of action and different toxic side effects. They are usually given in combination to enhance therapy. Dosage is not affected by giving the drugs in combination. The second and third drugs do not increase the effectiveness of the first. It is not true that the first two drugs are toxic to cancer cells while the third drug, promotes cell growth.