uworld Nclex - PN test 1 Questions with Correct Answers Rated A+

The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? - provide the client food in unopened, individually packaged food After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? - 5- year -old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree. The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? - what upsets you about having a hospital bed? The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? - The nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? - client receiving Iv normal saline at 250 ml / hr who is reporting puffy legs and a new cough An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? - Administer care until the parents or guardians can be reached. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? - I can start substituting breastfeeding sessions with whole cow's milk. The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? - Explain the client's wishes to the client child. The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? - what do you see at the door? The nurse reinforces teaching to a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? - stress the importance of consistent prenatal care A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? - what barrier methods do you and your partner(s) use? While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? - Firmly cover the insertion site with the palm of a clean, gloved hand The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? - Second degree A nurse in the emergency department is caring for 4 clients. Which client should the nurse see first? - Client with myasthenia gravis who has a fever and increasing difficulty swallowing The nurse is caring for a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? - I plan to attend my granddaughter's graduation next month. The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? - Let's talk more about how you have taking this medication The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? - Gloves The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? - Your belongings are locked in a safe place to ensure that they are protected while you are here. A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? Select all that apply. - Administer oxygen as needed if client becomes cyanotic Move the client from the chair to the floor to prevent a fall Record the duration of seizure activity for documentation A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL. The nurse expects the client's breakfast to arrive before 8 AM. What action should the nurse take? Click on the exhibit button for additional information. - Administer 37 units of insulin: 25 units of NPH insulin mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first The new nurse is reinforcing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? - be sure to take your valproic acid prior to the procedure The nurse is participating in a community health presentation about prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply. - apply a tick repellent spray before outdoor activities avoid hiking through areas of tall grass and thick under brush report bull's- eye rash or flu-like symptoms to the healthcare provider Wear a long sleeve shirt tucked into pants and clothes till shoes while hiking The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? - how are you feeling about your baby The nurse is reinforcing self-care and medication teaching for a client diagnosed with vaginal candidiasis who has been prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? - I will refrain from having sex until my partner is also tested and treated for the infection. A 4-year-old boy is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? - remove throw rugs from the home The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? - send the machine for maintenance and repeat the measurement manually The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. - instructs client that stockings will be worn only at night rolls down any excess length at the top of the stocking selects size larger to avoid friction against a leg laceration The nurse is reinforcing teaching to the caregiver of a client with a new prescription for risperidone. Which statement indicates that the caregiver needs further instruction? - it is normal for the client to become shaky and restless when agitated