Exam (elaborations) NCLEX RN

NCLEX RN DECEMBER FILES 3 VERSIONS 1. How to prevent a renal calculi? limit tea and chocolate 2. If a patient is in F-vib what medication to give? Adenosine 3. A nurse is caring for a patient and is unable to palpate a pedal pulse. What should the nurse do next? Obtain a doppler 4. A client with a history of COPD has established a walking program. How do we know that walking is effective? Cardiovascular improvement 5. A client complains of pain in the right calf. What is the nurse's priority? Remain in bed 6. A client just returned after having a TURP and has clot. What should the nurse do? slowly irrigate 7. What's Priority for a client with Multiple Scerolosis and has urinary rention? Self cathetherization 8. The nurse is monitoring drainainge of an abscess. What lab should the nurse monitor? WBCs 9. What intervetion the nurse shoudl implement for a patient with Congestive Heart Failure? Use bedside commode when needing to void 10.What intervention should be done for post op cataract extraction? implement deep breathing 11. A client is discharged on Prednisolone. What should the patient report? Wt gain 12. A client is diagnosed with Pyelinephritis. What is priority? IV antibiotics 13. What is a diet for Osteomalacia? Milk and cereal 14. What should the nurse instruct a client who has Raynuads Syndrome to do at work? Use space heater 15. What to teach a client with GERD? Wear loose clothing 16. How should a client with COPD breath? Pursed lips 17. A client presents with the s/s of Diabetes type 2 and feeling shaky. What is the nurse priority? Obtain glucose level 18. What should the HCP order for a client with Hypothyroidism who has depression and can not sleep? Request PRN... 19. What should a client with Ulcerative Colitis report? Stool with fatty streaks A. nurse is monitoring a client who is receiving parenteral nutrition (PN). Which of the following signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? a. Nausea, thirst, and increased urine output . 21. At 1600 the nurse checks a client’s parenteral nutrition (PN) infusion bag and finds 1100 mL remaining in the 3000-mL bag. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at: a) 1800 . 23. A nurse answers a call bell and finds that the parenteral nutrition (PN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which of the following actions should the nurse take first? a) Hanging a solution of 10% dextrose in water . A. young female client with schizophrenia says to the nurse, “Since I started on Zyprexa [olanzapine] last year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering me. What can I do about this?” Which response by the nurse would be therapeutic? a) “Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?” . 25.A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? a) Akathisia . 26.A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, “I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the client? a) “I think you need to come in for blood work today, because this may be a side effect of your medicine.” . 27.A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which of the following actions should the nurse take? Select all that apply. a) Removing the IV catheter at that site . b) Applying warm, moist compresses to the IV site . c) Notifying the healthcare provider about the finding . 28. A physician’s prescription reads, “Clindamycin phosphate (Cleocin Phosphate) 0.3 g in 50 mL NS, to be administered IV over 30 minutes.” The medication label reads, “Clindamycin phosphate (Cleocin Phosphate) 150 mg/mL.” How many milliliters of medication does the nurse prepare to ensure that the . dose is administered? In. . Responses: "2" 29.A physician’s prescription reads, “Phenytoin (Dilantin) 0.1 g by mouth twice daily.” The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose? In. . Responses: "1" 30.A nurse is preparing a plan of care for a client with renal colic who is receiving meperidine hydrochloride (Demerol) for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. a) Hypotension . b) Constipation . c) Urine retention . 31.A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which of the following actions does the nurse identify as a priority in the plan of care for this client? a) Monitoring the client’s respiratory rate . 32.A client who has been taking lisinopril (Prinivil) complains to the nurse of a persistent dry cough. The nurse tells the client that: a) This is a side effect of therapy . 34.A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. The nurse tells the client to: Place the patch in the area of a skin fold to promote adherence a) Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed . 35.A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. The nurse tells the client that: a) This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen (Tylenol) . 36. A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate (Cogentin) daily. Which intervention does the nurse identify as a priority in the plan? a) Monitoring intake and output . 37.A nurse is providing instructions to a client regarding quinapril hydrochloride (Accupril). The nurse teaches the client: a) To rise slowly from a lying to a sitting position . 38. 7. A female client with rheumatoid arthritis take ibuprofen (Motrin) 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol (Cytotec) 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching? A) Use contraception during intercourse. 39. In evaluating the effects of lactulose (Cephulac), which outcome should indicate that the drug is performing as intended? B) Two or three soft stools per day. 40. The healthcare provider prescribes naproxen (Naproxen) twice daily for a client with osteoarthritis of the hands. The client tells the nurse that the drug does not seem to be effective after three weeks. Which is the best response for the nurse to provide? C) Another type of nonsteroidal antiinflammatory drug may be indicated. 41. Which instruction(s) should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis? (Select all that apply.) A) Increase fluid intake, especially cranberry juice. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time. 42. A client receiving albuterol (Proventil) tablets complains of nausea every evening with her 9 p.m. dose. What action should the nurse take to alleviate this side effect? C) Administer the dose with a snack. 43. A client receiving Doxorubicin (Adriamycin) intravenously (IV) complains of pain at the insertion site, and the nurse notes edema at the site. Which intervention is most important for the nurse to implement? D) Discontinue the IV fluids. 44. A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? B) Dizziness. 45. The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A) Withhold the scheduled dose. 46. ) A client with rheumatoid arthritis is taking acetylsalicylic acid (aspirin) on a daily basis. Which medication dose should the nurse expect the client to be taking? 2. 4 g daily 47.) A nurse is caring for a client with gout who is taking Colcrys (colchicine). The client has been instructed to restrict the diet to low-purine foods. Which of the following foods should the nurse instruct the client to avoid while taking this medication? 2. Scallops 48.) A health care provider prescribes auranofin (Ridaura) for a client with rheumatoid arthritis. Which of the following would indicate to the nurse that the client is experiencing toxicity related to the medication? 4. Complaints of a metallic taste in the mouth 49.) A film-coated form of diflunisal has been prescribed for a client for the treatment of chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which initial instruction should the nurse provide to the client? 4. "Swallow the tablets with large amounts of water or milk." 50.) A health care provider instructs a client with rheumatoid arthritisto take ibuprofen (Motrin). The nurse reinforces the instructions, knowing that the normal adult dose for this client is which of the following? 3. 400 mg orally three times a day 51.) A adult client with muscle spasms is taking an oral maintenance dose of baclofen (Lioresal). The nurse reviews the medication record, expecting that which dose should be prescribed? 1. 15 mg four times a day 52.) A nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital following a back injury. Carisoprodol (Soma) is prescribed for the client to relieve the muscle spasms; the health care provider has prescribed 350 mg to be administered four times a day. When preparing to give this medication, the nurse determines that this dosage is: 1. The normal adult dosage 53.) A nurse has administered a dose of diazepam (Valium) to a client. The nurse would take which important action before leaving the client's room? 4. Per agency policy, putting up the side rails on the bed 54.) A client with a psychotic disorder is being treated with haloperidol (Haldol). Which of the following would indicate the presence of a toxic effect of this medication? 4. Excessive salivation 55.) Neuroleptic malignant syndrome is suspected in a client who is taking chlorpromazine. Which medication would the nurse prepare in anticipation of being prescribed to treat this adverse effect related to the use of chlorpromazine? 2. Bromocriptine (Parlodel) Rationale: 56.) A nursing student is assigned to care for a client with a diagnosis of schizophrenia. Haloperidol (Haldol) is prescribed for the client, and the nursing instructor asks the student to describe the action of the medication. Which statement by the nursing student indicates an understanding of the action of this medication? 4. It blocksthe binding of dopamine to the postsynaptic dopamine receptors in the brain. 57.) A client receiving lithium carbonate (Lithobid) complains of loose, watery stools and difficulty walking. The nurse would expect the serum lithium level to be which of the following? 4. 1.7 mEq/L 58.) When teaching a client who is being started on imipramine hydrochloride (Tofranil), the nurse would inform the client that the desired effects of the medication may: 2. Not occur for 2 to 3 weeks of administration 59.) A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse recognizes this complaint as a symptom of: 2. Postural hypotension 60. 68. An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac Toradol 30 mg IV q6h. Which action should the nurse implement? Administer both medications according to the prescription 61. Which assessment best determines the effectiveness of Sumatriptan (triptans are used for treatment of Migraines so… Termination of the migraine 62. Pt with schizophrenia is prescribed chlorpromazine (Thorazine – first generation antipsychotic) oral concentrate The medication may cause excessive salivation and no direct skin contact (both – not a good question) 63. Which best assessment best determines the pt is developing tardive dyskinesia Twisting, writhing, worm-like movements of tongue 64. Pt with depression is prIscribed Fluoxitine (Prozac) “It may take 3-4 weeks before my mood is elevated” 65. Pt is on Marplan (MAOIs – have the most food interactions) for depression Bananas, smoked fish, and cheese 66. Pt on Lithium Polydypsia (increased thirst), slurred speech, and fine hand tremors 67.Pt is prescribed Lunesta for insomnia Anterograde amnesia (memory loss of events right before taking drug) 68. A 24 yr female gets Triazolam (Halcion) for insomnia at home (remember to use the process of elimination) “The medication will not alter my breathing” 69. A pt is prescribed Venlafaxine and the pt asks what the purpose of medication is, you should state Depression and anxiety 70. . A client who was prescribed atorvastatin Lipitor one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the . drug-specific teaching the nurse should provide to this client? Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect 71. A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa Sinemet 25/100 PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? You can begin taking the Sinemet this evening, but do not take any more levodopa 72. A client is receiving methylprednisolone Solu-Medrol 40 mg IV daily. The nurse anticipates an increase in which laboratory value as the result of this medication? Serum glucose 73. A client with hyperlipidemia receives a prescription for niacin Niaspan. Which client teaching is most important for the nurse to provide? Expected duration of flushing 74. When assessing an adolescent who recently overdosed on acetaminophen Tylenol, it is most important for the nurse to assess for pain in which area of the body? Abdomen 75. The nurse is preparing the 0900 dose of losartan Cozaar, an angiotensin II receptor blocker ARB, for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? Withhold the scheduled dose 76. A nurse is caring for a client who reports recent amphetamine use. Which of the following manifestations should the nurse expect? Answer: Paranoia 77. A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider’srecommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client’s decision? Answer: Autonomy 78. A nurse isreinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? Answer: Have you considered participating in a sport to help control your aggression 79. A nurse on an inpatient mental health unit is supervising a group of clients in the unit’s dayroom. The nurse failsto respond to the escalating, aggressive behavior of a client eventually becomes violent and injures another client. For which of the following isthe nurse liable? Answer: Negligence 80. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findingsshould the nurse withhold the client’s medications and notify the provider? Answer: WBC count 81. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? Answer: The client who is experiencing command hallucinations 82. A nurse isreinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? Answer: You should listen to music when you feel stress 83. A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following action should the nurse take? Answer: Administer oxygen to the client 84. A nurse is caring for a client who has psychiatric symptom disorder. Which of the following actions should the nurse take? Answer: Encourage the client to examine how hisillness behavior affects hisfamily 85. A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? Answer: Have you had any thoughts of harming yourself 86. A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? Answer: Stand in front of the client when speaking 87. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? Answer: Naloxone 88. A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findingsshould the nurse identify as manifestations of bulimia nervosa? Answer: -Tooth erosion -Hand calluses -Hypokalemia 89.. nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Answer: Pupillary dilation 90. A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse includes? Answer: Dietitian 91. A nurse is assisting with discharge planning for a client who needs a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client’s discharge plan? Answer: Social worker 92. A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few momentslater,the client cheerfully states, “Now,here is my favorite social worker!” The nurse should identify the client is using which of the following defense mechanisms? Answer: Reaction formation 93. A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? Answer: A client who has borderline personality disorder and is pacing restlessly 94. A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information? Answer: I will probably feel irritable within 24 hours of my last cigarette 95. A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explainsthe therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts isthe nurse demonstrating? Answer: Veracity 96. A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Answer: Promote The development of problem-solving skills 97. A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? Answer: Feeling of hopelessness 98. A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? Answer: Administer haloperidol to a client who has schizophrenia and is yelling at other clients. 99.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? Answer: Offer liquid supplements to the client 100. A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and beginsthrowing objects at staff and other clients. After calling for assistance. Which of the following actions should the nurse take next? Answer: Tell the client calmly to sit down 101. A nurse caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse reports to the charge nurse? Answer: A client who is manic has been pacing the unit for several hours 102. A nurse is collecting data from a client who istaking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider? Answer: Bleeding gums 103. A nurse is attempting to resolve an ethical dilemma that involves a client’s medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? Answer: Determine the benefits and consequences of respecting the client’s medical Decisions 104. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? Answer: I will snap a rubber band on my wrist when I feel anxious about riding in a car 105. A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? Answer: A nurse does not notify the provider of a change in condition for a client who has schizophrenia 106. A nurse in a provider’s office is collecting data from an older adult client whose adult child reports that she “seems confused and can’t seem to remember much.”Which of the following findings should lead the nurse to suspect delirium? Answer: The client’s level of consciousness changes during the interview 107. A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She statesto the nurse,”I am so angry that my doctor didn’t take better care of me and my baby.” Which of the following responses should the nurse make? Answer: It is important to share what you are feeling, even if it is anger 108. A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? Answer: Establish and explain consequences for the client’s behavior 109. A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? Answer: Encourage the client to develop a safety plan 110. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client’s use of this substance? Answer: Hypertension 111. A nurse in a mental health facility is caring for a client who has dementia. The client’s agitation is increasing. Which of the following actions should the nurse take first? Answer: Offer diversionary activities 112. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? Answer: Determine the client’sintentions 113. A nurse isreinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? Answer: Do not drive until your reaction to the medication is determined 114. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, “My youngest child died 6 months ago while serving in the military.” Which of the following responses should the nurse make? Answer: -This must be very difficult time for you -Your child’s death must be a terrible loss -Tell me something you remember about your child 115. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client? Answer: Have the client’sfavorite snacks available at all times. 116. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? Answer: Projects blame onto others 117. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client? Answer: When you raise your voice, it makes me feel uncomfortable and unsafe.” 118. A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client’s confidentiality? Answer: The nurse places the client’s diagnosis on the white board in the client’s room 119. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findingsisreferred to as a negative symptom of schizophrenia? Answer: Apathy 120. A nurse in a long-term care center is caring for an adult client who has Alzheimer’s disease and whose partner died several years ago. The client appears upset and aslsthe nurse when his partner will visit again. The nurse states,”It seems like you are feeling lonely. Let’s take a walk outside and talk.’ Which of the following communication strategies is the nurse using? Answer: Validation therapy 121. A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statementsshould the nurse include in the teaching? Answer:” The voices you have been hearing should decrease.” 122. A nurse isreinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statementsshould the nurse identify as an indication that the client understands the information? Answer: “I should expect some improvement of my symptoms in about 10 days 123. A nurse is caring for a client who has major depressive disorder(MDD). The client states.”I have nothing to live for anymore. I just can’t go on.” Which of the following responses should the nurse make? Answer: Are you thinking about ending your life 124. A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist.”I know more than you do about the people in this room!” The nurse should identify that which of the following findings is the likely explanation for the client’s behavior? Answer: Hypomania 125. A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statementsshould the nurse make to gather information about the client’s ability to think abstractly? Answer: How is an orange similar to an apple 126.When medications have an additive, synergistic, or antagonistic effect on a tissue, a reaction has occurred. B. pharmacodynamic 127.Local anesthetics block the conduction of pain impulses to the spinal cord. Their duration of action: B. is determined by the rate of diffusion and absorption at the site of administration. 128. Which of the following clients should refrain from therapy with the thiazide diuretic hydrochlorothiazide (HCTZ)? C. a client with diabetes mellitus, type II 129. Delegation of tasks to appropriate personnel allows the nurse to: B. keep other members of the team productive. 130. A 50 milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at: A. 100 ml per hour for one hour. 132. Carrying a donor card for organ donation meansthat: C. a client is allowed to revoke his decision for organ donation at any time. 133. Referral for client education in the community can be accomplished through all of the following except: D. unlicensed massage therapists. 134.The tendency of a drug to combine with its receptor is called: D. affinity. 135. Social support systems include of the following except: D. use of coping skills and verbalization for anger management. Answer: D 136.In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess? A. ability to speak 137.In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except: C. bleeding problems. 138. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers? C. Suction the baby’s mouth and nose. 139.The drug of choice to decrease uric acid levels is: B. allopurinol (Zyloprim). 140. A corporate executive works 6080 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions? B. relaxation technique 141. A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage? C. Implement reverse isolation. 142.High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by: B. rapid cell catabolism. 143.Which isolation procedure will be followed for secretions and blood? B. Standard Precautions 144. Which of the following neurological disorders is characterized by writhing, twisting movements of the face and limbs? D. Huntington’s chorea Answer: D 145. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley’s level of anxiety as: C. severe. 146.Which of the following nursing diagnoses might be appropriate as Parkinson’s disease progresses and complications develop? A. Impaired Physical Mobility 147. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy’s mother indicates a need for further teaching by the nurse? C. "I should lay him on his back during a seizure." 148. Which of the following nursing actions is most effective when evaluating a kinetic family drawing? D. noting the omission of any family members 149.All of the following factors, when identified in the history of a family, are correlated with poverty except: D. low incidence of dental problems. 150. A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first? A. Open the airway. 151. A 2 1/2 year-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? B) Large wooden puzzle 152. A nurse is doing preconceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? C) "If I drink, my baby may be harmed before I know I am pregnant." 153. Post-procedure nursing interventions for electroconvulsive therapy include C) Remaining with client until oriented 154.The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which of the following interventions should take PRIORITY in planning care? B) Place client on a pressure reducing support surface 155. Which type of accidental poisoning would the nurse expect to occur in children under age six? A) Oral ingestion NCLEX DEC FILE 3 1. Which assessment best determines the effectiveness of Sumatriptan (triptans are used for treatment of Migraines so… Termination of the migraine 2. Pt with schizophrenia is prescribed chlorpromazine (Thorazine – first generation antipsychotic) oral concentrate The medication may cause excessive salivation and no direct skin contact (both correct – not a good question) 3. Which best assessment best determines the pt is developing tardive dyskinesia Twisting, writhing, worm-like movements of tongue 4. Pt with depression is prIscribed Fluoxitine (Prozac) “It may take 3-4 weeks before my mood is elevated” 5. Pt is on Marplan (MAOIs – have the most food interactions) for depression Bananas, smoked fish, and cheese 6. Pt on Lithium Polydypsia (increased thirst), slurred speech, and fine hand tremors 7.Pt is prescribed Lunesta for insomnia Anterograde amnesia (memory loss of events right before taking drug) 8. A 24 yr female gets Triazolam (Halcion) for insomnia at home (remember to use the process of elimination) “The medication will not alter my breathing” 9. A pt is prescribed Venlafaxine and the pt asks what the purpose of medication is, you should state Depression and anxiety 10. . A client who was prescribed atorvastatin Lipitor one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the correct drug-specific teaching the nurse should provide to this client? Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect 11. A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa Sinemet 25/100 PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? You can begin taking the Sinemet this evening, but do not take any more levodopa 12. A client is receiving methylprednisolone Solu-Medrol 40 mg IV daily. The nurse anticipates an increase in which laboratory value as the result of this medication? Serum glucose 13. A client with hyperlipidemia receives a prescription for niacin Niaspan. Which client teaching is most important for the nurse to provide? Expected duration of flushing 14. When assessing an adolescent who recently overdosed on acetaminophen Tylenol, it is most important for the nurse to assess for pain in which area of the body? Abdomen 15. The nurse is preparing the 0900 dose of losartan Cozaar, an angiotensin II receptor blocker ARB, for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? Withhold the scheduled dose 16. An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac Toradol 30 mg IV q6h. Which action should the nurse implement? Administer both medications according to the prescription 17. A nurse is caring for a client who has a depressive disorder and declines electroconvulsive therapy (ECT) despite the provider’srecommendation. Which of the following ethical principles is the nurse demonstrating by supporting the client’s decision? Answer: Autonomy 18. A nurse isreinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the following statements should the nurse make? Answer: Have you considered participating in a sport to help control your aggression 19. A nurse on an inpatient mental health unit is supervising a group of clients in the unit’s dayroom. The nurse failsto respond to the escalating, aggressive behavior of a client eventually becomes violent and injures another client. For which of the following isthe nurse liable? Answer: Negligence 20. A nurse is reviewing the medical record of a client who has schizophrenia. For which of the following findingsshould the nurse withhold the client’s medications and notify the provider? Answer: WBC count 21. A nurse on a mental health unit is caring for four clients who have schizophrenia. Which of the following clients should the nurse see first? Answer: The client who is experiencing command hallucinations 22. A nurse isreinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the following statements should the nurse make? Answer: You should listen to music when you feel stress 23. A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the following action should the nurse take? Answer: Administer oxygen to the client 24. A nurse is caring for a client who has psychiatric symptom disorder. Which of the following actions should the nurse take? Answer: Encourage the client to examine how hisillness behavior affects hisfamily 25. A nurse is caring for a client who recently lost his child in a motor-vehicle crash. The client is expressing feelings of hopelessness. Which of the following questions is the most important for the nurse to ask? Answer: Have you had any thoughts of harming yourself 26. A nurse is caring for a client who has dementia. Which of the following actions should the nurse take? Answer: Stand in front of the client when speaking 27. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? Answer: Naloxone 28. A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the following findingsshould the nurse identify as manifestations of bulimia nervosa? Answer: -Tooth erosion -Hand calluses -Hypokalemia 29.. nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? Answer: Pupillary dilation 30. A nurse is assisting with the planning of an interdisciplinary care conference for a newly admitted client who is in the acute stage of anorexia nervosa. Which of the following members of the interdisciplinary treatment team should the nurse includes? Answer: Dietitian 31. A nurse is assisting with discharge planning for a client who needs a day treatment center ad has limited community and financial support. Which of the following referrals should the nurse recommend for inclusion in the client’s discharge plan? Answer: Social worker 32. A nurse is speaking with a client who is expressing an intense disapproval of the current social worker. When the social worker approaches the nurse and client a few momentslater,the client cheerfully states, “Now,here is my favorite social worker!” The nurse should identify the client is using which of the following defense mechanisms? Answer: Reaction formation 33. A nurse on an inpatient unit is collecting data from a group of clients. Which of the following findings should the nurse report to the provider? Answer: A client who has borderline personality disorder and is pacing restlessly 34. A nurse is reinforcing teaching about expected withdrawal manifestations with a client who has enrolled in a smoking cessation course. Which of the following client statement indicates an understanding of the information? Answer: I will probably feel irritable within 24 hours of my last cigarette 35. A nurse is preparing to administer clozapine for the first time to a client who has schizophrenia. The nurse explainsthe therapeutic and adverse effects of the medication to the client prior to administration. Which of the following ethical concepts isthe nurse demonstrating? Answer: Veracity 36. A nurse is attempting to establish a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship? Answer: Promote The development of problem-solving skills 37. A nurse is collecting data from a client who has major depressive disorder. Which of the following findings is the priority for the nurse to report to the provider? Answer: Feeling of hopelessness 38. A nurse on a mental health unit is prioritizing care for a group of clients. Which of the following actions should the nurse take first? Answer: Administer haloperidol to a client who has schizophrenia and is yelling at other clients. 39.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following actions should the nurse include in the plan of care? Answer: Offer liquid supplements to the client 40. A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the dayroom and beginsthrowing objects at staff and other clients. After calling for assistance. Which of the following actions should the nurse take next? Answer: Tell the client calmly to sit down 41. A nurse caring for a group of clients on a mental health unit. Which of the following client behaviors should the nurse reports to the charge nurse? Answer: A client who is manic has been pacing the unit for several hours 42. A nurse is collecting data from a client who istaking valproic acid for the treatment of bipolar disorder. The nurse should identify that which of the following findings is priority to report to the provider? Answer: Bleeding gums 43. A nurse is attempting to resolve an ethical dilemma that involves a client’s medical decisions and his own personal values. After collecting data and identifying the problem, which of the following actions should the nurse take next? Answer: Determine the benefits and consequences of respecting the client’s medical Decisions 44. A nurse is reinforcing teaching about thought stopping with a client who has a phobia of riding in automobiles. Which of the following client statements indicates an understanding of the instructions? Answer: I will snap a rubber band on my wrist when I feel anxious about riding in a car 45.A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? a. that is called a caput succedaneum. it will absorb and cause no problems* 46.A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan? b. monitor skin and eyes for yellow tinge 47.The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/min, respiratory rate 16 breaths/min, andblood pressure 130/74. What action should the nurse implement? c. document the vital signs in the record 48.A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? d. you may be at higher risk for having a spontaneous miscarriage * 49.A pregnant woman who is at 10-weeks’ gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used toidentify Down Syndrome * 50.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately? c. nausea and vomiting 51. The HCP prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would causethe nurse to immediately discontinue the oxytocin? d. contraction duration of 100 seconds * 52. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority should the nurse address to ensure the newborn’s survival? c. heat loss 53.One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client * 54. The nurse is performing a newborn assessment. Which symptom, if present in a newborn would indicate respiratory distress? b. flaring of the nares * 55. A client receiving epidural anesthesia begins to experience nausea and becomes paleand clammy. What intervention should the nurse implement first? Raise the foot of the bed 56. What is the normal bilirubin at 1 day old? A. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. 57. How do we lower the levels if they are not severe? This infant's bilirubin is beginning to climb, and the infant should be monitored to prevent further complications. 58. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestationin preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor duringthe administration of this drug? Monitoring maternal and fetal heart rates is most important when terbutaline is beingadministered. 59. A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is thisnewborn likely to have exhibited? Choking, coughing, and cyanosis. 60. What does a child in respiratory distress look like? Apneic spells and grunting with prematurity orsepsis 62. What does a diaphragmatic hernia look like? Scaphoid abdomen and anorexia 63. A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."Which explanation should the nurse give to this anxious client? There's a strong, tough membrane there to protect the baby so you need not be afraidto wash or comb his/her hair. 64. A client who is attending antepartum classes asks the nurse why her healthcareprovider has prescribed iron tablets. The nurse's response is based on what knowledge? It is difficult to consume 18 mg of additional iron by diet alone. 65. What is megaloblastic anemia caused by? Folic acid deficiency 66. A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A home pregnancy test can be used right after your first missed period. 67. A 28-year-old client in active labor complains of cramps in her leg. What interventionshould the nurse implement? Extend the leg and dorsiflex the foot 68. When do the anterior and posterior fontanels close? anterior fontanel closes at 12 to 18 months and the posterior by the end of the secondmonth. 69. When assessing a client who is at 12-weeks gestation, the nurse recommends that sheand her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? 30 weeks gestation 70. The nurse should encourage the laboring client to begin pushing when? The cervix is completely dilated. 71. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Have the client breathe into her cupped hands 72. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does notcross the suture line is a newborn variation known as... a cephalohematoma, caused by forceps trauma and may last up to 8 weeks. 73. When does the head return to its normal shape? 7-10 days 74. What did Nurse theorist Reva Rubin describe? The initial postpartum period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, andcloseness to families and the newborn. 75. A couple, concerned because the woman has not been able to conceive, is referred to ahealthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which post procedure complaint indicates that the fallopian tubes are patent? Shoulder pain 76. Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" Lying prone with a pillow on the abdomen 77. he nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hyperthermia 78.A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client? a. When there is no significant vaginal bleeding. 79.A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, menopur), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately? c. Rapid increase in abdominal girth 80 .At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section),the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Inform the anesthesia care provider 81. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothersvaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first? a. Perform fundal massage until firm 82. A nurse in prioritizing care for four clients. Which of the following clients should the nurse assess first? An adolescent who has sickle cell anemia and slurred speech 83. A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new prescription for dornase alfa. Which of the following instructions should the nurse include the teaching? “Store the medication in the refrigerator.” 84. A nurse is caring for a child who has bacterial meningitis. Which of the following criteria indicates the nurse should remove the child from droplet precautions? Antibiotics initiated 24 hr ago 85. A nurse is assessing a school age child who has type 1 DM. The nurse notes that the child is diaphoretic. Which of the following actions should the nurse take? Obtain a blood glucose level 86. A nurse is caring for a child who is terminally ill. The parents tell the nurse that their child is going to be fine because they heard about another child who survived the same illness. Which of the following responses should the nurse make? “Tell me what you know about your child’s illness.” 87. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect? Steatorrhea 88. A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching? Apply bactericidal ointment to lesions 89. A nurse is preparing to administer naproxen 150 mg PO to a child who is experiencing pain. Available is naproxen 125 mg/ 5 ml solution. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 6 ml 90. A nurse is assessing a 6-month old patient at a well-child visit. Which of the following findings should the nurse expect? a. Closed posterior fontanel (8 weeks). 91. A nurse is caring for a 2-year old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose? a. ?? 92. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client’s plan of care? a. Encourage fluid intake at and between meals. 93. A nurse is planning care for a child who has suspected epiglottis. Which of the following actions should the nurse take? a. place the child in an upright position 94. A nurse is instructing a group of clients regarding calcium rich food. Which of the following should the nurse include in the teaching as the best source of calcium? a. 1 cup milk 95. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says “ I don’t understand why my child is so upset. I’ve never seen my child act this way around others before.” Which of the following statements should the nurse make? a. “This is a normal, expected reaction for a child of this age.” 96. A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child’s cooperation? a. Offer the child a choice of taking it with juice or water. 97. A nurse is caring for a client who requires droplet precautions. Which of the following Personal protective equipment should the nurse wear when setting up the meal tray? a. Mask 98. A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of The following actions by the client indicates an understanding of the teaching? a. The client holds his breath 10 seconds after inhaling the medication. 99. A nurse is caring for a 2-month-old infant who is post-operative following surgical repair of a cleft lip. Which of the following actions should the nurse take? a. Administer ibuprofen as needed for pain. 100. A nurse is caring for a child who has Kawasaki disease. Which of the following systems Should the nurse monitor in response to this diagnosis? a. Cardiovascular 101. A nurse is providing teaching to a client who has oral candidiasis and a new script for Nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching? a. “I will store the medicine at room temp” 102. A nurse is caring for a child who has been diagnosed with pertussis. Which type of precautions should the nurse take when caring for this child? Droplet precautions 103.A 7-year old girl is being seen at a healthcare clinic; the nurse suspects that the child is being neglected and physically abused at home. Beyond physical markings on the child, which of the following can also indicate signs of a child being abused or neglected? Select all that apply. The patient is wearing dirty, poorly-fitted clothes The patient misses school approximately once per week The child has body odor and rotting teeth 104.A nurse who works in the pediatric unit walks into a 3-year-old patient’s room and finds him lying on the floor. His parents are with him and they tell the nurse, “he fell out of bed!” Which response from the nurse is the most appropriate? Assist the patient back to bed, assess him for injuries and file an incident report 105. The nurse is conducting a physical examination in the ER of a child following a comprehensive health history. What should be the focus of the physical examination? Chief complaint 106. Which would be least effective in gaining the cooperation of a toddler during a physical examination? Tell the child that another child the same age wasn’t afraid. 107. The nurse is preparing a nursing care plan for an 8-year old child hospitalized for cardiac surgery. Which are examples of interventions that nurses perform in the “building a trusting relationship” stage? Select all that apply. Preparing the child for a procedure by playing games Explaining in simple terms what will be happening during surgery Giving the child a favorite toy to cuddle with following a painful procedure 108.A nurse is caring for a 13-year-old girl who is sexually active and whose partner is her 19-yearold boyfriend. The girl asks the nurse not to tell her parents about her sexual activity. This patient’s situation is best described as: statutory rap 109. An 11-year-old boy has been diagnosed with depression after his parents’ divorce. The nurse understands that depression in most children of this age most commonly manifests as: Lack of interest with friends and families 110.During the health history, the mother of a 4-month-old child tells the nurse she is concerned that her baby is not doing what he should be at this age. What is the nurse’s best response? “Tell me what concerns you.” 111.What is the role of the peer group in the life of school-age children? Provides them with security as they gain independence from their parents. 112.For which child would nonopioid analgesics be recommended? A child with juvenile arthritis 113.A nurse is working with a child who has a learning disability because she is unable to discriminate between different speech sounds. This disorder is most accurately described as: phonological processing deficit 114. The nurse is caring for an 11-year-old child who is experiencing pain related to chemotherapy treatment. What is a behavioral factor that might affect the child’s pain experience? Participation in normal routine activities 115. A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant? a. Trendelenburg? 116. A nurse is caring for a client who has a prescription for digoxin 0.25mg PO daily. The amount available is 0.125mg tab. The client’s current vital signs are: BP 144/96, hear rate 54/min, respirations 18/min, and temperature 98.6 F. Which of the following actions should the nurse take? a. Withhold for decreased pulse rate. 117. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? a. “My teacher says my child has to squint to see the board.” 118. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries Do to a motor-vehicle crash. Identify the sequence of actions the nurse should take. 1. Open airway using a jaw-thrust maneuver 2. Determine effectiveness of ventilator efforts 3. Establish IV access 4. Glasgow Coma Scale assessment 5. Remove clothing for a thorough assessment. 119. A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching? a. “I will give my child strained carrots and mashed egg yolks.” 120. A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? a. Inspect the mouth for signs of inhalation injuries 121. A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client? a. Private room 122. A nurse is reviewing the lab findings for a client who has ITP. Which of the following findings should the nurse expect to be decreased? a. Platelets 123. A nurse is assessing a client who has SLE. Which of the following findings should the nurse expect? a. Facial rash 124. A nurse is creating a plan of care for a school-age child who has nephrotic syndrome. Which of the following interventions should the nurse include? (Select all that apply) • Provide a low-sodium diet • Assess for protein in the urine • Obtain a daily weight 125. A nurse in a pediatric unit is caring for a school-age child following a cardiac catheterization. Which of the following interventions would the nurse take? • Keep the affected extremity straight for 6 hrs. 126. A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates understanding of the teaching? • “I should give my child water after giving the medication.” 127. A nurse is caring for a 9-year-old child who has major burns to her face and upper torso. Which of the following actions should the nurse take first? • Give pain medication 128. A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following should the nurse include in the plan of care? • Cleanse the gums with saline soaked gauze 129. A nurse in a community health clinic is assessing the needs of a single parent who has three young children and works full time. Which of the following resources should the nurse recommend? • Respite child care 130. A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 4. Women who have implants are often able exclusively to breastfeed. 131. A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby’s and mother’s infection? 4. Candida albicans. 132. A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 133. A woman, 26 weeks’ gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 134. A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 4. Provide the client with supervised instruction on baby care skills. 135. A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediola