NCLEX Practice Exam

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NursesLabs.comNCLEX 5e ect All That Apply Practice Exam1 . A p a t i e n t is a d m i t t e d t o t h e s a m e d a y s u r g e r y u n i t for l i v e r b i o p s y . W h i c h o f t h e f o l l o w i n g l a b o r a t o r yt e s t s a s s e s s e s c o a g u l a t i o n ? S e l e c t a l l t h a t a p p l y .1 . Partial t h r om b o p astin time.2 . P r o t h r o m b i n t i m e .3 . P l a t e l e t c o u n t .4 . H e moglocii n5 . Complete B l o o d C o u n t6 . White B l o o d Cell C o u n tA n s w e r : 1 , 2 , a n d 3Frochr e m a i n time., p a r t i a l t h r o m b o a l a s t i n t i m e . a n d a l a t e l e t c o u n t are a I i n c l u d e d i n c o a g u l a t i o n studies. T h e h e m o g o a i nl e v e l , t h o u g h important information p r i o r t o a n i n v a s i v e p r o c e d u r e l i k e l i v e r b i o p s y , d o e s n o t assess c o a g u a t i o n .2 . A p a t i e n t is a d m i t t e d t o t h e h o s p i t a lw i t h s u s p e c t e d p o l y c y t h e m i a v e r a . W h i c h o f t h e f o l l o w i n g s y m p t o m si s c o n s i s t e n t with t h e d i a g n o s i s ? S e l e c t a l l thata p p l y .1 . W e i g h t loss.2 . I n c r e a s e d c l o t t i n g t i m e .3 . H ypertensian.4 . Headaches.A n s w e r : 2 , 3 , a n d 4P o l y c y t h e m i a vera is a c o n d i t i o n i n w h i c h the b o n e m a r r o w p r o d u c e s too m a n y r e d a l o o d c e l s . T h i s causes a n i n c r e a s e i nh e m a t o c r i t a n d v s e o s i t y o f the b o o d . P a t i e n t s c a n e x p e r i e n c e h e a d a c h e s , dizziness, a n d visual d i s t u r b a n c e s .Cardio vascu a r effects i n c l u d e i n c r e a s e d b l o o d pressure a n d d e l a y e d c l o t t i n g t i m e . W e i g h t loss i s n o t a manifestation o fp o l y c y t n e m i a vera.Pafte3 . T h e n u r s e i s t e a c h i n g t h e c l i e n t h o w t ou s e a m e t e r e d d o s e i n h a l e r ( M D I ) t o a d m i n i s t e r a C o r t i c o s t e r o i dd r u g . W h i c h o f t h e f o l l o w i n g c l i e n t a c t i o n s i n d i c a t e s thath e i s u s i n g t h e M D I c o r r e c t l y ? S e l e c t a l l t h a t a p p l y .1 . T h e i n h a l e r is h e l d u p r i g h t .2 . H e a d i s t i l t e d d o w n while i n h a l i n g t h e m e d i c a t i o n3 . C l i e n t v s its 5 m i n u t e s b e t w e e n puffe.4 . M o u t h i s rinsed with water fol o w n g a d m i n i s t r a t i o n5 . C l i e n t lies s u p i n e fa'-1 5 m i n u t e s fo l o w i n g a d m i n i s t r a t i o n .A n s w e r : 1 a n d 4 .4 .T h e n u r s e is t e a c h i n g a c l i e n t with p o l y c y t h e m i a v e r a about p o t e n t i a l c o m p l i c a t i o n s f r o m t h i s d i s e a s e .W h i c h m a n i f e s t a t i o n s w o u l d t h e n u r s e i n c l u d e i n t h e c l i e n t ' s t e a c h i n g p l a n ? S e l e c t a l l thata p p l y .1 . H e a r i n g l o s s2 . V i s u a l disturbance3 . H e a d a c h e4 . O r t h o p n e a5 . G o u t6 . W e i g h t lossA n s i v e r s : 2 , 3 ,4 a n d5 .P o l y c y t h e m i a vera, a c o n d i t i o n i n w h i c h too m a n y RBCs a r e p r o d u c e d in t h e b l o o d s e r u m , c a n l e a d t o a n increase i n theh e m a t o c r i t a n d hypervo e m i a , h y p e r v i s c o s i t y , a n d h y p e r t e n s i o n . S u b s e q u e n t l y , the c l i e n t c a n experience d i z z i n e s s ,t i n n i t u s , visual d i s t u r b a n c e s , h e a d a c h e s , o r a feeling o f f u l l n e s s i n the h e a d . T h e c l i e n t m a y a s o e x p e r i e n c ec a r d i o v a s c u l a r s y m p t o m s s u c h a s h e a r t f a i l u r e { s h o r t n e s s o f b r e a t h a n d o r t h o p n e a ) a n d i n c r e a s e d c l o t t i n g t i m e o rC Ns y m p t o m s o f a n i n c r e a s e d uric a c i d l e v e l s u c h a s p a i n f u l s w o l e n joints ( u s u a l y t h eo i g t o e ) . H e a r i n g loss a n d weight lossare n o t manifestations a s s o c i a t e d with p o y c y t h e m a vera.

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5 .W h i c h o f t h e f o l l o w i n g w o u l d b e p r i o r i t y a s s e s s m e n t d a t a t o g a t h e r from a c l i e n t w h o h a s b e e n d i a g n o s e dwith p n e u m o n i a ? S e l e c t a l l t h a t a p p l y .1 . Auscultation o f breath s o u n d s2 . A u s c u l t a t o n o f Dowel s o u n d s3 . Presence o f c h e s t p a i n .4 . Presence o f peripheral e d e m a5 . Color o f n a i l b e d sA n s w e r : 1 , 3 , 5 .A r e s p i r a t o r y a s s e s s m e n t , vrfiich i n c l u d e s a u s c u l t a t i o n o f breath s o u n d s a n d assessing tne c o l o r o f the n a i l b e d s ,s apriority for c l i e n t s with p n e u m o n i a . Assessing for the presence o f c h e s t p a i n i s a l s o a n i m p o r t a n t r e s p i r a t o r y assessmentas chest p a i n c a n interferewith the c l i e n t s a b i l i t y t o breathe d e e p l y . A u s c u l t a t i n g b o w e l s o u n d s a n d assessing forp e r i D h e r a l e d e m a m a y b e a p p r o p r i a t e a s s e s s m e n t s , but t h e s e a r e n o t p r i o r i t y assessments for the p a t i e n t withp n e u m o n i a .6 . T h e n u r s e i s t e a c h i n g a c l i e n t w h o h a s b e e n d i a g n o s e d with TB h o w t o a v o i d s p r e a d i n g t h e d i s e a s e t of a m i l y m e m b e r s . W h i c h s t a t e m e n t ( s ) b y t h e c l i e n t i n d i c a t e ( s ) t h a t h e h a s u n d e r s t o o d t h e n u r s e si n s t r u c t i o n s ? S e l e c t a l l t h a t a p p l y .1 . " I will n e e d t o d i s p o s e o f m y o l d c l o t h i n g when I return h o m e . "2 . " I s h o u l d a l w a y s c o v e r m y m o u t h a n d nose when sneezing."3 . ' I t i s i m p o r t a n t that I isolate m y s e l f foom family v h e n p o s s i b l e . "4 . ' I s h o u l d use p a p e r t i s s u e s t o c o u g h i n a n d d i s p o s e o f t h e m p r o p e r l y."5 . " I c a n u s e r e g u l a r p l a t e a n d utensils w h e n e ir I eat."C OA n s i v e r : 2 , 4 , 5 .7 . T h e n u r s e is a d m i t t i n g a c l i e n t w i t h h y p o g l y c e m i a . I d e n t i f y t h e s i g n s a n d s y m p t o m s t h e n u r s e s h o u l de x p e c t . S e l e c t a l l t h a t a p p l y .1 . Thirst2 . P a l p i t a t i o n s3 . D i a o h o r e s s4 . Slurred s p e e c h5 . H y p e r v e n t i l a t i o nA n s i v e r : 2 , 3 , 4 .P a l p t a t i o n s , a n a d r e n e r g i c s y m p t o m , o c c u r a s the g l u c o s e l e w i sfell; the s y m p a t h e t i c nervous s ystem i s activated a n deoinephrine a n d n o r e o i n e p h r i n e a r e secreted c a u s i n g t h i s response. D i a p h o r e s i s i s a s y m p a t h e t i c n e r v o u s s y s t e mr e s p o n s e that o c c u r s a s e p i n e p h r i n e a n d n o r e p i n e p h r i n e a r e r e l e a s e d . S l u r r e d s p e e c hs a n e u r o g l y c o p e n i c symptom; a sthe b r a i n receives insufficient g l u c o s e , t h e a c t i i t y o f t h e CMS b e c o m e s d e p r e s s e d .8 .W h i c h a d a p t a t i o n s s h o u l d t h e n u r s e c a r i n g for a c l i e n t with d i a b e t i c k e t o a c i d o s i s e x p e c t t h e c l i e n t t oe x h i b i t ? S e l e c t a l l t h a ta p p l y :1 . Sweating2 . L o w PCO23 . R e t i n o p a t h y4 . Acetone b r e a t h5 . E l e v a t e d s e r u m b i c a r b o n a t eAnswer: 2 , 4 .M e t a b o l i c a c i d o s i s i n i t i a t e s r e s p i r a t o r y c o m p e n s a t i o n i n the form o f K u s s m a u l respirations t o c o u n t e r a c t the effects o fk e t o n e b u i l d u p , r e s u l t i n g i n a lowered PCO2. A fruity o d o r t o the b r e a t h ( a c e t o n e breath) o c c u r s vrfienthe ketone l e v e l i se l e v a t e d i n k e t o a c i d o s i s .

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9 .W h e n p l a n n i n g c a r e for a c l i e n twith u l c e r a t i v e colitis w h o i s e x p e r i e n c i n g s y m p t o m s ,w h i c h c l i e n t c a r ea c t i v i t i e s c a n t h e n u r s e a p p r o p r i a t e l y d e l e g a t e t o a u n l i c e n s e d a s s i s t a n t ? S e l e c t a l l t h a t a p p l y .1 . Assessing t h e client's b o w e l s o u n d s2 . P r o v i d i n g s k i n c a r e following b o w e l m o v e m e n t s3 . E v a l u a t i n g t h e c l i e n t s response t o a n t i d i a r r h e a l m e d c a t i o n s4 . M a i n t a i n i n g i n t a k e a n d o u t p u t r e c o r d s5 . O b t a i n i n g the c i e n t s weight.A n s w e r : 2 , 4 , a n d 5 .T h e nurse c a n d e l e g a t e t h e folio wing basic care a c t i v i t i e s t o the u n l i c e n s e d assistant: p r o v i d i n g s k i n cane folllowing bowelm o v e m e n t s , m a i n t a n i n g i n t a k e a n d o u t p u t r e c o r d s , a n d o atai n in g the c l i e n t s weight. Assessing t h e c ient's b o w e l s o u n d sa n d e v a l u a t i n g the c l i e n t s response t o m e d i c a t i o n are r e g i s t e r e d nurse a c t i v i t i e s t h a t c a n n o t b e d e l e g a t e d .1 0 .V 4 i i c h o f t h e f o l l o w i n g n u r s i n g d i a g n o s e s would b e a p p r o p r i a t e for a c l i e n twith heart f a i l u r e ? S e l e c t a l lt h a t a p p l y .1 . Ineffective tissue p e r f u s i o n rotated t o d e c r e a s e d o e r i p h e r a l b l o o d flow s e c o n d a r y t o d e c r e a s e d c a r d i a c o u t o u t .2 . Activity i n t o l e r a n c erelated t oi n c r e a s e d cardiac o u t p u t .3 . D e c r e a s e d cardiac o u t p u t rotated t o structural a n d f u n c t i o n ac h a n g e s .4 . I m p a i r e d g a s e x c h a n g erelated t od e c r e a s e d s y m p a t h e t i c nervous s y s t e m activity.A n s w e r : 1 a n d 3 .HF is a r e s u l t o f structural a n d functional a b n o r m a l i t i e s o f the h e a r t tissue m u s c l e . T h e h e a r t m u s c l e b e c o m e s weak a n dd o e s not a d e q u a t e l y p u m p t h e b l o o d o u t o f t h e c h a m b e r s . A s a r e s u l t , b l o o d p o o l s i n t h e left ventricle a n d backs u p i n t oL Othe left a t r i u m , a n d e v e n t u a l l y into the l u n g s . Therefore, g r e a t e r a m o u n t s o f b l o o d r e m a i n i n t h e ventricle aftercontraction t h e r e b y d e c r e a s i n g cardiac output. I n a d d i t i o n , t h i s p o o l i n g leads t o t h r o m b u s formation a n d ineffective tissuePagep e r f u s i o n b e c ause o f t h e d e c r e a s e i n b l o o d flow t otheo t h e r o r g a n s a n d t i s s u e s o f t h e b o d y . T yoically, t h e s e d i e nts h a vea n e j e c t i o n fract o n o f less t h a n 5 0 % a n d pooriy t o l e r a t e a c t i v i t y . A c t i v i t y i n t o l e r a n c e i s related t o a d e c r e a s e , n o ti n c r e a s e , i n c a r d i a c o u t p u t . G a s e x c h a n g e is i m p a r e d . H o w e v e r , the d e c r e a s e i n c a r d i a c o u t p u t triggers c o m p e n s a t o r ym e c h a n i s m s , s u c h a s a n increase i n s y m p a t h e t c n e r v o u s s y s t e m a c t vity.1 1 .W h e n c a r i n g for a c l i e n t with a c e n t r a l v e n o u s l i n e , w h i c h o f t h ef o l l o w i n g n u r s i n g a c t i o n s s h o u l d b ei m p l e m e n t e d i n t h e p l a n o f c a r e f o r c h e m o t h e r a p y a d m i n i s t r a t i o n ? S e l e c t a l l t h a t a p p l y .1 . V e r i f y p a t e n c y o f t h e line b y t h e p r e s e n c e o f a o l o o d return a t rogular interva s.2 . I n s p e c t t h e i n s e r t i o n s i t e for s w e l l i n g , e r y t h e m a , o r d r a i n a g e .3 . A d m i n i s t e r a c y t o t o x c a g e n t t o k e e p t h e r e g i m e n o n s c n e d u l e e v e n i f b l o o d return i s n o t p r e s e n t .4 . I f u n a b l e t o a s p i r a t e b l o o d , reposition t h e c l i e n t a n d e n c o u r a g e t h e c l i e n t t o c o u g h .5 . C o n t a c t thehealthcareprovider a b o u tverifying p a c e m e n t i f tne status is q u e s t i o n a b l e .A n s w e r : 1 , 2 , 4 , 5 .A major c o n c e r n withntra v e n o u s a d m i n i s t r a t i o n o f c y t o t o x i c a g e n t s i s vessel i r r i t a t i o n o r e x t r a v a s a t i o n . T h e O n c o l o g yN u r s i n g S o c i e t y a n d h o s p i t a l g u i d e l i n e s r e q u i r e frequent e v a l u a t i o n o f b l o o d return when a d m i n i s t e r i n g vesicant o r n o nv e s i c a n t c h e m o t h e r a p y d u e t o the r i s k o f e xtra vasation. T h e s e g u i d e l i n e s a p p y t o p e r i p h e r a l a n d c e n t r a l venous l i n e s . I na d d i t i o n , c e n t r a l v e n o u s l i n e s m a y b e l o n g - t e r m v e n o u s a c c e s s d e vices. T h u s , d i f f i c u l t y drawing o r a s p i r a t i n g b l o o d m a yi n d i c a t e t h e l i n e is a g a i n s t thevessel wall o r m a y i n d i c a t e the line h a s o c c l u s i o n . H a ving t h e c l i e n t c o u g h o r m o v e positionm a y c h a n g e the status o f t h e l i n ei fit is t e m p o r a r i l y a g a i n s t a vessel wall. O c c l u s i o n warrants more t h o r o u g h e v a l u a t i o nvia x - r a y s t u d y t o '.erify p l a c e m e n t i f the status i s q u e s t i o n a b l e a n d m a y r e q u i r e a d e c l o t t i n g r e g i m e n .1 2 . A 2 0 - y e a r o l d c o l l e g e s t u d e n t h a s b e e n b r o u g h t t o t h e p s y c h i a t r i c hospital! b y h e r p a r e n t s . H e r a d m i t t i n gd i a g n o s i s i s b o r d e r l i n e p e r s o n a l i t y d i s o r d e r .W h e n t a l k i n g with t h e p a r e n t s ,w h i c h i n f o r m a t i o n w o u l d t h en u r s e e x p e c t t o b e i n c l u d e d i n t h e c l i e n t ' s h i s t o r y ? S e l e c t a l l t h a t a p p l y .

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1 . I m p u l s i v e n e s s2 . L a b i l i t y o f m o o d3 . Ritualistic b e h a v o r4 . p s y c h o m o t o r retardation5 . Self-destructive b e h a v i o rI B .W h e n a s s e s s i n g a c l i e n t d i a g n o s e d w i t h i m p u l s e c o n t r o l d i s o r d e r , t h e n u r s e o b s e r v e s v i o l e n t ,a g g r e s s i v e , a n d a s s a u l t i v e b e h a v i o r .W h i c h o f t h e f o l l o w i n g a s s e s s m e n t d a t a i s t h e n u r s e a l s o l i k e l y t o f i n d ?S e l e c t a l l t h a t a p p l y .1 . T h e c l i e n t fun e to n s welli no t h e r a r e a s o f h i s I fe .2 . T h e d e g r e e o f a g g r e s s i v e n e s s i s o u t o f p r o p o r t i o n t o t h e stressor.3 . T h e v i o l e n t b e h a v i o r i s m o s t often justified b y the stressor.4 . T h e c l i e n t h a s a history o f p a r e n t a l a l c o h o l i s m a n d c h a o t i c , a b u s ve femi y life.5 . T h e c l i e n t h a s n o remorse a b o u t t h e i n a b i l i t y t o c o n t r o l h i s a n g e r .A n s w e r : 1 , 2 , 4 .A c l i e n twitha n i m p u se c o n t r o l disorder w h o displa ys violent, aggressi ve,a n da s s a u l t i v e b e h a vior g e n e r a l y functions welli n o t h e r areas o f h i s life. T h e d e g r e e o f aggressi vsness i s t y p i c a l l y o u t o f o r o p o r t i o n with the stressor. S u c h a c l i e n tc o m m o n y has a h i s t o r y o f oarencal a c o h o l i s m a n d a c h a o t i c femil y life, a n d often veroal z e s sincere remorse a n d g u i l t ferthe a g g r e s s i v e b e h a v i o r .1 4 .W h i c h o f t h e f o l l o w i n g n u r s i n g i n t e r v e n t i o n s a r ewritten c o r r e c t l y ? ( S e l e c t a l l thata p p l y . )1 . A p p l y c o n t i n u o u s p a s s i v e motion m a c h i n e d u r i n g d a y .2 . Performneurovascularc h e c k s .3 . Elevate h e a d o f b e d 3 0 d e g r e e s before m e a l s .4 . C h a n g e d r e s s i n g o n c e a s h i f t .A n s w e r : 3 .It is specific i n what t o d o a n d w h e n .1 5 . The n u r s e i s monitoring a c l i e n t r e c e i v i n g peritoneald i a l y s i s a n d n u r s e n o t e s t h a t a c l i e n t ' s o u t f l o w i sl e s s t h a n t h e i n f l o w . S e l e c t a c t i o n s t h a t t h e n u r s e s h o u l d t a k e .1 . Placethec i e n ti ng o o d b o d y a l i g n m e n t2 . C h e c kthelerel o f t h e d r a i n a g e b a g3 . Contact t n e p h y s i c i a n4. Cheek the perito neaI d i aI ysis s ystem fbr kinks5 . R e p o s i t i o n the c i e n t t o h i s o r h e r side.A n s w e r : 1 , 2 , 4 , 5 .I f outflow d r a i n a g e i s i n a d e q u a t e , the n u r s e attempts t o s t i m u l a t e outflow b y c h a n g i n g t h e c l i e n t s p o s t i o n . T u r n i n g t h ec l i e n t t o t h e o t h e r s i d e o r m a k i n g sure t h a t the c l i e n t i s i n g o o d bod y a l i g n m e n t m a y assist with o u t flow d r a i n a g e . T h ed r a i n a g e o a g n e e d s t o b eo w e r t h a n t i ec l i e n t s a b d o m e n t o e n h a n c e gravity dra n a g e . T h e c o n n e c t i n g t u b i n ga n dt h ep e r i t o n e al d i aI ysis s ystem i s a so c h e c k e d for k i n k s o rt wsein g a n d t n e c l a m p s o n the s ystem a r e c h e c k e d to e n s u r ethatt h e y a r e o p e n . T nere i s n o r e a s o n t o contact t h e p h y s i c i a n .1 6 . The n u r s e i s c a r i n g f o r a h o s p i t a l i z e d c l i e n tw h o h a s c h r o n i c r e n a l f a i l u r e . W h i c h o f t h e f o l l o w i n g n u r s i n gd i a g n o s e s a r e m o s t a p p r o p r i a t e for t h i s c l i e n t ? S e l e c t a l l t h a t a p p l y .1 . Excess Fluid V o l u m e2 . I m o a l a n c e d N u t r i t i o n ; Less t h a n B o d y R e q u i r e m e n t s3 . Activity I n t o l e r a n c e4 . I m p a i r e d G a s E x c h a n g e0 05 . Pain.|

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A n s w e r : 1 , 2 , 3 .Appropriate n u r s i n g d i a g n o s e s fer c ients with c h r o n i c renal l a i ure inc u d e excess fluid v o l u m e r e l a t e d t o fluid a n d s o d i u mretention; i m b a l a n c e d n u t r i t i o n , less t h a n b o d y r e q u i r e m e n t s re ated t o a n o r e x i a , nausea, a n d v o m i t i n g : a n d a c t v i t yi n t o l e r a n c e related t o fetigue.Tne n u r s i n g d i a g n o s e s o f impaired gas e x c h a n g e a n d p a i n a r e n o t c o m m o n l y r e l a t e d t ochronic r e n afailure.1 7 . T h e n u r s e i s a s s e s s i n g a c h i l d d i a g n o s e d with a b r a i n t u m o r . W h i c h o f t h e f o l l o w i n g s i g n s a n d s y m p t o m sw o u l d t h e n u r s e e x p e c t t h e c h i l d t o d e m o n s t r a t e ? S e l e c t a l l t h a t a p p l y .1 . H e a d t i l t2 . Vomiting3 . Polydipsia4 . L e t h a r g y5 . Increased appetite6 . Increased pulseA n s w e r : 1 , 2 , 4 .H e a d tilt, v o m i t i n g , a n d l e t h a r g y a r e classic s i g n s assessed in a c h i l d with a b r a i n t u m o r . Clinical manifestations are t h er e s u l t o fo c a t i o n a n d size o f the t u m o r .1 8 . T h e n u r s e i s c a r i n g for a c l i e n t with a T 5 c o m p l e t e s p i n a l c o r d i n j u r y . U p o n a s s e s s m e n t , t h e n u r s e n o t e sf l u s h e d s k i n , d i a p h o r e s i s a b o v e t h e T5, a n d a b l o o d p r e s s u r e o f 1 6 2 / 9 6 . T h e c l i e n t reports a s e v e r e ,p o u n d i n g h e a d a c h e .W h i c h o f t h e f o l l o w i n g n u r s i n g i n t e r v e n t i o n s would b e a p p r o p r i a t e for t h i s c l i e n t ?S e l e c t a l l t h a t a p p l y .1 . Elevate t h e HOB t o 9 0 degreesCT*2 . L o o s e n constrictive c l o t h i n g2?3 . Use a fen t o r e d u c e diaphoresis4 . Assess for b l a d d e r d i s t e n t i o n a n d b o w e l i m p a c t i o n5 . A d m i n i s t e r a n t i h y p e r t e n s i v e medication6 . Place the c l i e n t i n a s u p i n e p o s i t i o n with l e g s e l e v a t e dA n s i v e r : 1 , 2 , 4 , 5 .T h e c l i e n t has signs a n d s y m p t o m s o f a u t o n o m i c d y s r e f l e x a . T h e p o t e n t i a l l y life-threatening c o n d i t i o n is c a u s e d b y a nu n i n h i b i t e d response from tne sympathetic n e r v o u s system resulting from a l a c k o f control o v e r t h e a u t o n o m i c n e r v o u ssystem.T h e n u r s e s h o u l d i m m e d i a t e l y e l e v a t e t h e HOB t o 9 0 d e g r e e s a n d p ace e x t r e m i t i e s d e p e n d e n t l y t o decreasevenous return t o the heart a n d increase 'venous return from t h e brain. Because t a c t i l e s t i m u l i c a n trigger a u t o n o m i cdysreflexia, a n y c o n s t r i c t i v e c l o t h i n g s h o u l d b eo o s e n e d . T h e nurse s h o u d also assess for distended□l a dd e ' a n d b o v/eli m p a c t i o n , which maytriggera u t o n o m i c dysreflexia, a n d c o r r e c t a n y p ' o b l e m s . E l e v a t e d b l o o d pressure i s the most life-threatening c o m p l i c a t i o n o f a u t o n o m i c dysreflexia because it c a n c a u s e s t r o k e , M l , o r seizures. I f r e m o v i n g the triggeringe v e n t d o e s n ' t reduce t h e c l i e n t s b o o d p r e s s u r e , I V a n t i h y p e r t e n s i v e s s h o u l d b e administered. A fen s h o u dn't be u s e dbecause c o l d drafts m a y t r i g g e ' a u t o n o m i c d y s r e f l e x a .1 9 . T h e n u r s e i s e v a l u a t i n g t h e d i s c h a r g e t e a c h i n g for a c l i e n t w h o h a s a n i l e a l c o n d u i t .W h i c h o f t h ef o l l o w i n g s t a t e m e n t s i n d i c a t e s t h a t t h e c l i e n t h a s c o r r e c t l y u n d e r s t o o d t h e t e a c h i n g ? S e l e c t a l l that a p p l y .1 . " I f I l i m i t m y fluid i n t a k e I will not h a v e t o e m p t y m y o s t o m y p o u c h a s o ften."2 . ' I c a n p ace a n aspirin tablet i n m y p o u c h t o decrease odor.*3 . ’ I c a n u s u a l l y k e e p m y o s t o m y p o u c h o n for 3 t o 7 days oefore c h a n g i n g it."4 . ' I m u s t use a s k i n harrier t o p r o t e c t m y s k i n from urine."5 . ' I s h o u l d e m p t y m y o s t o m y p o u c h o f urine when i t i s full."OfaSodAns wer: 3 , 4 .T h e c i e n t with a n ileal c o n d u i t m u s tearn self-care activities r e l a t e d t o c a r e o f the s t o m a a n d o s t o m y a p p i a n c e s . T h ec l i e n t s h o u l d b e taught t o increase fluid intake t o a b o u t 3,001} m l p e r d a y a n d s h o u l d not l i m i t i n t a k e . Adequate fluid

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i n t a k e h e l p s t o flush m u c u s from the ileal c o n d u i t . T h e o s t o m y a p p l i a n c e s h o u l d b e c h a n g e d a p p r o x i m a t e l y er y 3 t o 7days a n d w h e n e v e r ae a k d e veloos. A s k i n banners essential to p r o t e c t i n g the s k i n from t h e i r r t a t i o n o f the u r i n e . A na s p i r i n s h o u l d n o t b e u s e d as a m e t n o d o f o d o r c o n t r o l b e c a u s et c a n b e a n irritant t o the stoma a n d l e a d t o ulceration.T h e o s t o m y p o u c h s h o u l d oe e m p t i e d w h e n it i s one-th nd t o o n e - h a f fult o p r e v e n t t h e weight from p u l l i n g the a p o l a n c ea w a y from the s k n .2 0 . A n u r s e is a s s i s t i n g i n p e r f o r m i n g a n a s s e s s m e n t o n a c l i e n t w h o s u s p e c t s t h a t s h e i s p r e g n a n t a n d i sc h e c k i n g t h e c l i e n t for p r o b a b l e s i g n s o f p r e g n a n c y .Select allp r o b a b l e s i g n s o f p r e g n a n c y .1 . Uterine e n l a r g e m e n t2 . Fetal h e a r t rate d e t e c t e d b y n o n e l e c t r i c d e v i c e3 . Outline o f t h e fletus via r a d i o g r a p h y o r ultrasound4 . Chadwick's s i g n5 . B r a x t o n H i c k s c o n t r a c t i o n s6 . Bal o t t e m e n tA n s w e r s : 1 , 4 , 5 , a n d 6 .T n ep r o b a b l esigns o f p r e g n a n c y i n c l u d e :•Uterine E n l a r g e m e n t■Hegar's s g n o r s o f t e n i n g a n d t h i n n i n g o f t h e uterine s e g m e n t t h a t o c c u r s a t w e e k 6 .•Goodell's s i g n o r s o f t e n i n g o f t h e cervi x t h a t o c c u r s a t the b e g i n n i n g o f t h e 2 n d m o n t h"Chadwick's s i g n o r b l u i s h c o l o r a t i o n o f t h e m u c o u s m e m b r a n e s o f t h e ceriax, vagina a n d v u l v a . Occurs a tweek6 .'B a l l o t t e m e n t o r r e b o u n d i n g o f t h e flatus a g a i n s t the e x a m n e t s fingers o f palpation•Braxton-Hicks contractions'Positive p r e g n a n c y test m e a s u r i n g forhCG.Positive s i g n s o f p r e g n a n c y include:PageJ•Fetal H e a r t Rate d e t e c t e d b y e l e c t r o n i c d e v i c e (doppler) a t 1 0 - 1 2 weeks•Fetal H e a r t rate detected b y nonelectronic d e v i c e (fetoscope) a t 2 0 weeks AOG•A c t i «fetal m o v e m e n t palpable b y the e x a m i n e r s•Outline o f t h e fetus via r a d i o g r a p h y o r ultrasound2 1 . A n u r s e is m o n i t o r i n g a p r e g n a n t c l i e n t with p r e g n a n c y i n d u c e d h y p e r t e n s i o n w h o i s a t r i s k forP r e e c l a m p s i a . T h e n u r s e c h e c k s t h e c l i e n t forw h i c h s p e c i f i c s i g n s o f P r e e c l a m p s i a ( s e l e c t a l l t h a t a p p l y ) ?1 . Ele vat e d olood pressure2 . N e g a t i v e u r i n a r y p r o t e i n3 . Facial eolema4 . Increased resp rationsA n s w e r : 1 a n d 3 .T h e three classic signs o f p r e e c l a m p s a are h y p e T e n s i o n , g e n e r a l i z e d e d e m a , a n d p r o t e i n u r i a . Increased r e s p i r a t i o n s a r en o t a s i g n o f p r e e c a m p s a .22. A n u r s e is c a r i n g for a p r e g n a n t c l i e n t with s e v e r e p r e e c l a m p s i a w h o i s r e c e i v i n g I V m a g n e s i u m s u l f a t e .Selectalln u r s i n g i n t e r v e n t i o n s t h a t a p p l y i n t h e c a r e for t h e c l i e n t .1 . M o n i t o r m a t e r n a l vital signs e v e r y 2 h o u r s2 . Notify t h e p h ysician i f respirations a r e less t h a n 1 8 p e r m i n u t e3 . M o n i t o r renal: function a n d cardiac function c l o s e l y4 . Keep c a l c i u m g l u c o n a t e o n h a n d i n case o f a m a g n e s i u m sulfete overdose5 . M o n i t o r d e e o t e n d o n reflexes h o u r l y6 . Monito’’ I a n d O's h o u r l y7 . Notify tine p h y s i c i a n i f u r i n a r y o u t p u tse s s t h a n 30 m l p e r h o u r .

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A n s w e r s :3 , 4 , 5 , 6 , a n d 7 .W h e n c a r i n g fcr a c l i e n t r e c e i v i n g m a g n e s i u m sulfate t h e r a p y , the nurse would m o n i t o r m a t e r n a l vital s i g n s , e s p e c i a l l yr e s p i r a t i o n s , e v e r y 3 0 - 6 0 m i n u t e sa n d notifythe p h y s i c i a n i f respirations are less t h a n 1 2 , b e c a u s e t h i s would i n d i c a t er e s p i r a t o r y depression. C a l c i u m g l u c o n a t es kept o n h a n d i n c a s e o f m a g n e s i u m sulfate o v e r d o s e , oecause c a l c i u mgluconaze is t h e a n t i d o t e form a g n e s i u m sulfate t o x i c i t y . D e e p t e n d o n reflexes are assessed h o u r l y . Cardiac a n d r e n a lf u n c t i o n is m o n i t o r e d closel y. T h e urine o u t p u t s h o u l d be m a i n t a i n e d a t 3 0 m l p e r h o u r b e c a u s e t h e m e d c a t i o n i se i m i n a t e d t h r o u g h t h e k i d n e y s .2 3 .W h e n i n t e r p r e t i n g a n E C G , t h e n u r s ewould k e e p i n m i n d w h i c h o f t h e f o l i o w i n g a b o u t t h e P w a v e ?S e l e c t a l l t h a t a p p l y .1 . R e f e c t s electrical i m p u l s e b e g i n n i n g a t the SA n o d e2 . I n d i c a t e d e e c t r i c a l i m p u l s e b e g i n n i n g a t t h e AV n o d e3 . R e f e c t s a t r i a l m u s c l e d e p o l a r i z a t i o n4 . Identifiesventricular m u s c l e d e p o l a r i z a t i o n5 . Has d u r a t i o n o f n o r m a l l y O . i l seconds o r less.A n s w e r : 1, 3 , 5 .I n a c l i e n t who h a s h a d a n ECG,theP wave r e p r e s e n t s t h e a c t i v a t i o n o f the e l e c t r i c a l i m p u l s e i n t h e SA n o d e , w h i c h i st h e n t r a n s m i t t e dtothe A V n o d e . I n a d d i t i o n ,theP wave represents a t r i a l m u s c l e d e p o l a r i z a t i o n , not v e n t r i c u a rd e p o l a r i z a t i o n . T h e n o r m a l d u r a t i o n o f t h e P wa ve i s 0 . 1 1 s e c o n d so rlessi nd u r a t i o na n d2 . 5 m m o r m o r e i n h e i g h t .2 4 .W h e n c a r i n g for a c l i e n t with a c e n t r a l v e n o u s l i n e , which o f t h ef o l l o w i n g n u r s i n g actions s h o u l d b ei m p l e m e n t e d i n t h e p l a n o f care for c h e m o t h e r a p y a d m i n i s t r a t i o n ? S e l e c t a l l t h a t a p p l y ,1 . V e r i f y p a t e n c y o f t h e line b y t h e p r e s e n c e o f a b l o o d r e t u r n a t r e g u l a r i n t e r v a s.2 . I n s p e c t the i n s e r t i o n s i t e for s w e l l i n g , e r y t h e m a , o r drainage.3 . A d m i n i s t e r a cytotoxic a g e n t t o k e e p t h e r e g i m e n o n s c h e d u l e e v e n i f b l o o dreturn isn o t present.Pa»e1 4Page1 34. I f u n a b e t o a s p i r a t e b l o o d , reposition t h e c l i e n t a n d encourage t h e c l i e n t t o c o u g h .5 . Contact the h e a l t h care p r o v i d e r a b o u t ve1-fyi n g pl a c em en t i f the status is q u e s t i o n a b l e .A n s w e r : 1 , 2 , 4 , 5 .A m a j o r c o n c e r n with i n t r a v e n o u s administration o f c y t o t o x i c a g e n t s i s vessel i r r i t a t i o n o r e x t r a v a s a t i o n . T h e O n c o l o g yN u r s i n g S o c i e t y a n d h o s p i t a l g u i d e l i n e s require frequent e v a l u a t i o n o f b l o o d return when a d m i n i s t e r i n g vesicanto r nonvesicant c h e m o t h e r a p y d u e t o the risk o f e x t r a vasati o n . T h e s e g u i d e i n e s a p p y t o p e r i p h e r aa n d central venous l i n e s . I na d d i t i o n , c e n t r a l v e n o u s l i n e s m a y b e l o n g - t e r m v e n o u s a c c e s s d e vices. T h u s , d i f f i c u l t y drawingo ra s p i r a t i n g b l o o d m a yi n d i c a t e t h e line is a g a i n s t tnevessel wall o'" m a y i n d i c a t e t h e line h a s o c c l u s i o n . H a ving t h e c l i e n t c o u g h o r m o v e positionm a y c h a n g e the status o f t h e l i n ei fit is t e m p o r a r i l y a g a i n s t avesselwall.O c c l u s i o n w/arrancs more t h o r o u g h e v a l u a t i o nvia x-ray s t u d y t o 'verify p l a c e m e n t i f the status i s q u e s t i o n a b l e a n d m a y r e q u i r e a d ecl o t t i n g r e g i m e n .2 5 . T o assist a n a d u l t c l i e n t t o s l e e p b e t t e r t h e n u r s e r e c o m m e n d s w h i c h o f t h e f o l l o w i n g ? ( S e l e c t a l l t h a ta p p l y . )1 . D r i n k i n g a g ass o f wine just before r e t i r i n g t o b e d2 . E a t i n g a l a r g em e a l1hourbefore b e d t i m e3 . C o n s u m i n g a s m a l l glass o f vrarm m i l k a t b e d t i m e4 . Performing m i d e x e r c ses 3 0 m i n u t e s before g o i n g t o o e dA n s w e r : 3 .A s m a l l glass o f m iIkrelaxes t h e b o d y a n d p r o m o t e s sleep.2 6 . T h e n u r s e r e c o g n i z e s t h a t a c l i e n t i s e x p e r i e n c i n g i n s o m n i a w h e n t h e c l i e n t r e p o r t s ( s e l e c t a l l t h a ta p p l y ) :1 . E x t e n d e d time t o fall a s l e e p2 . Falling a s l e e p a t i n a p p r o p r i a t e t i m e s

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3 . Di fficulty staying a s l e e p4 . F e e l i n g t i r e d after a night’s s l e e pA n s w e r : 1 , 3 , a n d 4 .T h e s e symptoms are often r e p o r t e d b y c l i e n t s with i n s o m n i a . Clients report nonresto rati v e s l e e p . Arising o n c e a t n i gF t t ourinate ( n o c t u r i a ) i s not i n a n d o f i t s e l f i n s o m n i a .2 7 .T h e n u r s e t e a c h e s t h e m o t h e r o f a n e w b o r n t h a t i n o r d e r t o p r e v e n t s u d d e n i n f a n t d e a t h s y n d r o m e( S I D S ) t h e b e s t p o s i t i o n t o p l a c e t h e b a b y a f t e r n u r s i n g i s ( s e l e c t a l l t h a t a p p l y ) :1 . P r o n e2 . S i d e - l y i n g3 . S u n i n e4 . Fowler'sA n s w e r : 2 a n d 3 .R e s e a r c h d e m o n s t r a t e that t h e o c c u r r e n c e o f SIDS i s r e d u c e d w t h t h e s e t w o p o s i t i o n s .2 8 . A c l i e n t h a s a d i a g n o s i s o f p r i m a r y i n s o m n i a . B e f o r e a s s e s s i n g t h i s c l i e n t , t h e n u r s e r e c a l l s t h en u m e r o u s c a u s e s o f t h i s d i s o r d e r . S e l e c t a l l t h a ta p p l y :1 . C h r o n i c s t r e s s2 . Severe a n x i e t y3 . G e n e r a l i z e d p a i n4 . E x c e s s i v e caffeine5 . C h r o n i c d e p r e s s i o n6 . E n v i r o n m e n t a l noiseS IsSu,|9 1A n s w e r : 1 , 4 , a n d 6 .Acute o r o r i m a r y n s o m n i a i s c a u s e d b y e m o t i o n a l o r ohysical discomfort n o t c a u s e d b y the d i r e c t physiologic effects o f asubstance o r a m e d i c a l c o n d t i o n . Excessive caffeine intake is a n e x a m p l e o f disrupt! ws l e e p h y g i e n e ; caffeine i s as t i m u l a n t t h a t i n h i b i t s sleep. E n v i r o n m e n t a l noise c a u s e s p h y s i c a l a n d / o r e m o t i o n a l a n d therefore is r e l a t e d t o p r i m a r yi n s o m n a.2 9 . S e l e c t a l l t h a t a p p l y t o t h e u s e o f b a r b i t u r a t e s i n t r e a t i n g i n s o m n i a :1. Barbiturates d e p r i v e oeople o f NREM s l e e p2 . Barbiturates d e p r i v e oeople o f REM sleep3 . W h e n the b a r b i t u r a t e s are d i s c o n t i n u e d , t h e NREM s l e e p increases.4 . W h e n t n e bafoiturates a ' e d i s c o n t i n u e d , t h e REM s l e e p increases.5 . N i g h t m a r e s a r e often a n adverse e'Hect when d i s c o n t i n u i n g barbiturates.A n s w e r : 2 , 4 , a n d 5 .Barbiturates d e p r i v e p e o p l e o f REM sleep. W h e n t h e b a r b i t u r a t e i s stopped a n d REM s l e e p o n c e a g a i n occurs, a r e b o u n dp h en o m e n o n o c c u r s . D u r i n g t h i s p h e n o m e n o n , the p e r s o n s d r e a m t i m e constitutes a l a r g e r p e r c e n t a g e o f the t o t a l s l e e ppattern, a n d the d r e a m s are often n i g h t m are s .3 0 . S e l e c t a l l t h a t a p p l y t h a t i s a p p r o p r i a t ew h e n t h e r e is a b e n z o d i a z e p i n e o v e r d o s e :1 . A d m i n i s t r a t i o n o f s y r u p o f i p e c a c2 . Gastric l a vage3 . Activated c h a r c o a l a n d a saline cathartic4 . H e m o d al ysis5 . A d m i n i s t r a t i o n o f Flum a z e n i lA n s w e r : 2 , 3 , a n d 5 .

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I f i n g e s t i o n is r e c e n t , d e c o n t a m i n a t i o n o f t h e G l s y s t e m is indicated. T h e a d m i n i s t r a t i o n o f syrup o f ipecac i sc o n t r a i n d i c a t e d because o f a s p r a t i o n r i s k s related t o sedation. Gastric lavage i s g e n e r a l l y the b e s t a n d most effectivem e a n s o f g a s t r i c d e c o n t a m i n a t o n . A c t i v a t e d c h a r c o a l a n d a s a l i n e cathartic m a y oe a d m i n i s t e r e d t o r e m o v e a n yr e m a i n i n g d r u g . H e m o d i a l y s i s is not u s e f u linthe treatment o f b e n z o d i a z e p i n e o v e r d o s e . F l u m a z e n i l c a n be u s e d t oa c u t e l y re verse the s e d a t i v e effocts o f benzodiazepines, t h o u g h t h i s is n o r m a l l y d o n e o n l y i n c a s e s o f e x t r e m e o verdoseors e d a t i o n .1 . A 6 - y e a r - o l d c h i l d with l e u k e m i a i s h o s p i t a l i z e d a n d i s r e c e i v i n g c o m b i n a t i o n c h e m o t h e r a p y . L a b o r a t o r yr e s u l t s i n d i c a t e t h a t t h e c h i l d i s n e u t r o p e n i cra n d t h e n u r s e p r e p a r e s t o i m p l e m e n t protective i s o l a t i o np r o c e d u r e s . W h i c h i n t e r v e n t i o n s would t h e n u r s e i n i t i a t e ? S e l e c t a l l t h a t a p p l y .1 . Restrictallvisitors.2 . Place the c h i l d o n ao w - b a c t e r i a diet.3 . C h a n g e dressings using sterile t e c h n i q u e .4 . Encourage t h e c o n s u m p t i o no ffresh fruits a n d vegetables.5 . Perform m e t i c u l o u s h a n d washing before c a r i n g for t h e child.6 . A l l o w fresh-cut flowers i n t h e r o o m as l o n g as t h e y are k e p t i n a vase with fresh wacer.A n s w e r : 2 , 3 , a n d 5 .For the hosoitalized n e u t r o p e n i c c h i l d , flo wers o r p l a n t s s h o u l d n o t b e k e p t i n the room because s t a n d i n g wrater a n d d a m psoil h a r b o r Aspergillus a n d Pseudomonas, t o which t h e s e c h i l d r e n a r e very susceptible. Fruits a n d vegetables n o t p e e l e dbefore b e i n g e a t e n h a r b o r m o l d s a n d s h o u l d be a v o i d e d until the white b l o o d c e l l c o u n t rises. T h e c h i l d i s p l a c e d o n alow-bacteriad i e tDressings a r e a l w a y s c h a n g e d wich s t e r i l e t e c h n i q u e . N o tallvisitors n e e d to b e restricted, b u t a n y o n ewhoi s i l l s h o u l d n o t oe a l l o w e dintne child's r o o m . Meticulous h a n d washing i s r e q u i r e d before caring for t h e child.Ina d d i t i o n ,gloves, a m a s k , a n d a g o w n are worn ( p e r a g e n c y p o l i c y ) .Page172 . A 1 6 - y e a r - o l d c h i l d i s b r o u g h t t o t h e e m e r g e n c y d e p a r t m e n t b y h i s m o t h e rwith a c o m p l a i n t t h a t t h e c h i l dj u s t e x p e r i e n c e d a t o n i c - c l o n i c s e i z u r e . O n a r r i v a l i n t h e e m e r g e n c y d e p a r t m e n t n o a p p a r e n t s e i z u r e s w e r eo c c u r r i n g . T h e m o t h e r states t h a t h e r s o n i s t a k i n g m e d i c a t i o n for t h e s e i z u r e d i s o r d e r . T h e n u r s e p l a n sc a r e , k n o w i n g thatw h i c h o f t h e f o l i o w i n g m e d i c a t i o n s a r e u s e d for l o n g - t e r m c o n t r o l o f t o n i c - c l o n i cs e i z u r e s ? S e l e c t a l l t h a t a p p l y .1 . D a z e p a m ( V a l i u m )2 . A l p r a z o l a m ( X a n a x )3 . G a b a p e n t i n ( N e u r o n t i n )4 . E t h o s u x i m i d e (Zarontin)5 . C a r b am a z e n i n e ( T e g r e t o l )6 . M e t h y l p h e n i d a t e (R t a iin)A n s w e r s : 3 , 4 , a n d 5 .M e d i c a t i o n s that are p r e s c r i b e d foro n g- t e r m c o n t r o l o f tonic-clonic se zures are g a b a p e n t i n , e t h o s u j c m i d e , a n dc a r b a m a z e o i n e . D i a z e p a m is a m e d i c a t i o n t h a t i s prescribed t o halt tonic -clonic e p i s o d e s , a n d m e t h yd□h e n date i s am e d i c a t i o n u s e d t o t r e a t a t t e n t i o n d e f i c i t hyperactivity d i s o r d e r . Both o f t h e s e m e d i c a t i o n s a r e not s u i t a b l e fa" l o n g - t e r mc o n t r o l o f a seizure c o n d i t i o n . A l p r a z o l a m i s a m e d i c a t i o n used t o treat a n x i e t y .3 . A c h i l d h a s b e e n d i a g n o s e d with m e n i n g o c o c c a l m e n i n g i t i s . W h i c h o f t h e f o l l o w i n g i s o l a t i o n t e c h n i q u e s i sa p p r o p r i a t e ?1 . Enteric p r e c a u t i o n s2 . N e u t r o p e n i c p r e c a u t i o n s3 . N o p r e c a u t i o n s are r e q u red aso n g as antibiotics h a v e b e e n s t a r t e d .4 . I s o l a t i o n precautions for a t l e a s t 2 4 h o u r s after the i n i t i a t i o n o f a n t i b i o t i c sAnswer: 4 .

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