EXAM Pass the NCLEX – Study Guide 2024

EXAM Pass the NCLEX – Study Guide 2024 A 4-year-old client has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first? - Irrigate the NG tube to ensure patency. Explanation: If the NG tube isn't draining properly or is kinked, the child will experience nausea. Therefore, the nurse should check the tube's patency and irrigate it as ordered. There is no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case. A client diagnosed with renal calculi is experiencing severe pain despite having received pain medication. A nurse pages a physician. Which intervention can the nurse perform while awaiting the physician's response? - Perform nonpharmacologic pain interventions. Explanation: The nurse should institute non-pharmacologic pain measures to help control the client's pain until the physician responds. These include repositioning, massage, and distraction. A client experiencing severe pain will most likely be able to tolerate a higher dose of pain medication. Although ambulation is sometimes effective in mobilizing renal calculi, the client is most likely experiencing too much pain to ambulate at this time. The nurse can't apply a heating pad without a physician's order. A client expressed interest in using complementary alternate modalities for health benefits and asks the nurse to provide information about meditation. The nurse would provide which appropriate response to this client - It consists of deep personal thoughts and breath control to help decrease anxiety. Explanation: Meditation strives to clear the mind with deep breathing and personal thoughts. Herbalists use herbs and plants to promote health. Therapeutic touch teaches that each person is surrounded by an energy field. In acupressure, the client applies external pressure to the energy points for pain control. When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? - 1. Monitor the skin for breakdown daily during the client's bath. 2. Keep skin clean and dry to prevent breakdown. 3. Turn and reposition the client every two hours. Explanation: Because healthy skin is the body's first line of defense, a key nursing goal is to keep the skin intact. The nurse can accomplish this goal by keeping the skin clean and dry to prevent breakdown. To reduce moisture, the nurse can apply a nonirritating dusting powder, such as cornstarch, to the client's axillae and groin, beneath the breasts, and between the toes after those areas are dry. However, scented powder should not be used because it can irritate the skin. Deodorants and antiperspirants should not be applied to the skin immediately after shaving because they can cause irritation. The nurse should use lotion for backrubs because rubbing alcohol dries the skin and can irritate it. Daily inspection of the skin will catch any problems early. Turning the client every two hours will prevent the development of pressure areas over the bony prominences A client with a knee-to-toe cast applied informs the nurse that they are having severe itching in the ankle area and need something to scratch it with. What is the priority nursing action? - A. Encourage the client to avoid scratching, and confer with the health care provider if severe itching persists. Explanation: Clients should not scratch inside casts because of the risk of skin breakdown and potential damage to the cast. The nurse should consider notifying the health care provider if itching persists. The health care provider may prescribe an antihistamine, such as diphenhydramine, to relieve itching. Sedatives are not generally indicated for itching. A blow dryer on the heat setting could cause burns and increase itching due to vasodilation. Using it on the cool setting may be of some relief. A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective? A. The child lies down to rest after eating. B. The toddler finishes the meal within a specified period of time. C. The child eats finger foods independently. D. The toddler stays neat while eating. - Answer: The child eats finger foods independently. Explanation: A child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to self-feed. Because spasticity affects coordinated chewing and swallowing, as well as the ability to bring food to the mouth, it is difficult for a child with cerebral palsy to eat neatly. Inde