NCLEX PN Saunders Assessment Practice 4 (Answered)

NCLEX PN Saunders Assessment Practice 4 (Answered) caring for a patient with flu like symptoms plenty of rest, increase intake of fluids, encourage client take antipyuretics to decrease fever. plan of action for the emergency department, in an event of internal fire. direct ambulating clients to walk to a safe location, remove all clients from danger before attempting to extinguish the fire, move bedridden clients away from the fire are by use of beds or stretchers. pregnant client receiving MAGNESIUM SULFATE for management of PREECLAMPSIA. client is experiencing toxicity from medication respirations of 10 bpm toxicity= cns depressant effects, respirations lower than 12 per minute, a LOSS of deep tendon reflexes, a sudden drop in fetal HR or maternal HR and BP. protienuria is noted 3+ in preeclampsia tb skin test administered to an individual with HIV. 72 hrs later your document should show POSITIVE results with area of induration at the test site measuring 7mm. normally area of induration greater than 15 mm is considered positive in low-risk. 5mm + in individuals with HIV infection is considered positive. An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent. Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply. Encourage frequent urination, Continue maternal and fetal assessments, Review breathing and relaxation techniques. Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor... client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition? An episode of diarrhea Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply Eat smaller and more frequent meals. Drink fluids between meals not with them. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals not with them to avoid dumping syndrome. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? "No eating or drinking for at least 18 hours before the surgery." Rationale: The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing per mouth (NPO) for 18 hours before surgery. A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet? Ice cream Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply. Place the child on a low-bacteria diet, Change dressings using sterile technique,Perform meticulous hand washing before caring for the child. Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy). Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item?