NCLEX

The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the 1. first stage of labor who has an oral temperature of 99.7° F (37.6° C) 2. first stage of labor whose contractions are occurring every 30 seconds 3. second stage of labor who has respirations of 26 4. second stage of labor whose contractions are lasting for 60 seconds - correct answer 2. first stage of labor whose contracti...

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1. The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response? A. Answer any questions the employer may have as he pays for the insurance. B. Tell the employer his question is inappro...

Reduce symptoms of Raynauds disease? - Wearing gloves when handling frozen food What is Raynauds disease? - reduced blood flow due to spasm of arteries of the feet and hands When removing a chest tube, what should you instruct the patient to do? - hold breathe and bear down When you notice blanching, coldness and edema at the IV site, what should you do? - Remove the IV What is considered a normal Blood Glucose level? - 70-100 What PPE to use for MRSA patient? - Gloves Gown Goggles Mask...

When selecting an NCLEX answer or determining the order of priority what should you remember or use and what is the exception? - Use the ABC rule: Airway breathing, and circulation. The exception to the rule is with actual CPR, use C-A-B for CPR. Also remember safety first and acute before chronic. If the pt. is not in distress then you assess. If the pt is in distress then you should do something. If the pt has diaphorisis you should always do something. How should you address questions re...

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1. We need to encourage adequate fluid intake 2. Coughing spells may be triggered by dust or smoke 3. We need to maintain respiratory precautions & a quiet environment for at least 2 weeks 4. Good hand-washing techniques need to be instituted to pre...

The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience: - throbbing headache or dizziness. A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia? - Dyspnea, tachycardia, and pallor The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client? - Limit foods ...

Select the member of the healthcare team that is paired with one of the main functions of this team member. A. Occupational therapist: Gait exercises B. Physical therapist: The provision of assistive devices to facilitate the activities of daily living C. Speech and language therapist: The treatment of swallowing disorders D. Case manager: Ordering medications and treatments - *Correct Response: C* Speech and language therapists assess and treat patients with a swallowing disorder; they al...

The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. Reye's syndrome4. Scarlet fever - Correct Answer: 3 RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the...

the nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to: A. Nasal congestion B. Abdominal Tenderness C. Muscle Tetany D. Oliguria - A. Nasal congestion why? removal of the pituitary gland is usually done by transsphernoidal approach through the nose. Nasal congestion further interferes with the airway. A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6,...

The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding? 1. Increase in Forced Vital Capacity (FVC) 2. A narrowed chest cavity 3. Clubbed fingers 4. An increased risk of cardiac failure - 3. Clubbed fingers - CORRECT Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels. The nurse is taking the...