Preparation for NCLEX 2 Flashcards
Just prior to administering lorazepam 2 mg I.V. to an agitated client, the client knocks the medication to the floor. After retrieving the medication, what is the best action by the nurse?
a. Ask another nurse to witness the waste of the medication.
b. Attempt to administer the medication to the client.
c. Place the syringe with the medication into the sharps container.
d. Dispose of the medication into the sink.
a. Ask another nurse to witness the waste of the medication.
Lorazepam is a Schedule IV controlled substance. Federal law requires two nurses to witness and document the waste of all controlled substances in order to prevent diversion and misuse of the substance. The nurse should ask another nurse to witness the waste of the medication either into the sink or an approved pharmaceutical waste container as per the facility policy. Controlled substances should never be placed into a sharps container as these are not secure and may lead to diversion of the substance. A nurse would not administer a medication that had been knocked to the floor as this would result in contamination of the syringe.
A 36-year-old multigravid client at 12 weeks’ gestation has a history of chronic hypertension and obesity. The client was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when they make which statement?
a. “I need to reduce my caloric intake to 1200 calories a day.”
b. “A regular diet is recommended during pregnancy.”
c. “I should eat more frequent meals if I get heartburn.”
d. “I need to consume more fluids and fiber each day.”
a. “I need to reduce my caloric intake to 1200 calories a day.”
Pregnancy is not an appropriate time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant clients report that eating more frequent, smaller meals decreases heartburn caused by the reflux of acidic secretions into the lower esophagus. Clients who are pregnant need adequate hydration (fluids) and fiber to prevent constipation.
On a crisis shelter hotline, the nurse talks to two 11-year-old children who think a friend has inhalant use disorder. They say their friend’s breath sometimes smells like glue and they act drunk. They say they are afraid to tell their parents about the friend. When the nurse is formulating a reply, what is the most important factor for the nurse to consider?
a. The callers probably fear punishment.
b. Inhalant use is illegal.
c. The callers’ observations could be wrong.
d. Inhalant use is a minor form of substance use disorder.
a. The callers probably fear punishment.
Telephoning the crisis shelter indicates that the children are alarmed but are reluctant to talk with their parents. They may fear that their parents will assume that they have been using inhalants and punish them. The nurse should focus on helping the children talk with their parents. The legality of using inhalants varies, but crisis hotlines are geared at providing supportive services. To prove that the observations are incorrect requires an intervention beginning with the children’s parents. Inhalant use disorder is a very dangerous, not minor, form of substance use disorder.
A client has a ureteral catheter in place after renal surgery. What should the nurse do to provide safe care of the ureteral catheter?
a. Irrigate the catheter with 30 mL of normal saline every 8 hours.
b. Ensure that the catheter is draining freely.
c. Clamp the catheter every 2 hours for 30 minutes.
d. Ensure that the catheter drains at least 15 mL per hour.
b. ensure that the catheter is draining freely.
The ureteral catheter should drain freely without bleeding at the site. The catheter is rarely irrigated, and any irrigation would be done by the health care provider (HCP). The catheter is never clamped. The client’s total urine output (ureteral catheter plus voiding or indwelling urinary catheter output) should be at least 30 mL per hour.
A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse’s interaction with the client, which is the nurse’s best response?
a. “Using drugs jeopardizes your health and you should consider quitting.”
b. “If tested, you will lose your job.”
c. “You could easily have an error in judgement and cause a serious accident.”
d. “There’s a problem with you choosing to use drugs as a way to cope with the stressors you experience.”
c. “You could easily have an error in judgement and cause a serious accident.”
Because the nurse’s statement refers to those who could be harmed as a result of the pilot’s drug use, the nurse’s suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes the client’s health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with their use of drugs to cope with stress reflects the principle of autonomy by addressing how the client’s actions influence the rights of others.
A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to
a. install safety devices in the home.
b. wear worn, comfortable shoes.
c. get help when lifting objects.
d. wear protective devices when exercising.
a. install safety devices in the home.
Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren’t usually necessary when the client exercises.
The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.
a. The spouse places soiled dressing supplies in the kitchen garbage can.
b. Disinfectant spray is used on the table where dressing supplies are prepared.
c. Clean gloves are used for wound dressing removal.
d. Sheets with wound drainage are washed in lukewarm water.
e. Dressing supplies are placed in a clean, dry location.
f. Routine hand hygiene is performed before and after care.
a. The spouse places soiled dressing supplies in the kitchen garbage can.
d. sheets with wound drainage are washed in lukewarm water.
Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care.
In discharge planning after scleral buckling for a detached retina, the nurse should teach the client to avoid which activity during the early recovery period?
a. watching television
b. reading
c, talking on the telephone
d. walking in the yard
b. reading
Reading involves too much jerky eye movement and should be avoided during recovery.
Watching television, talking on the telephone, and walking outdoors are appropriate activities and can be encouraged.
A primigravid client at 34 weeks’ gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. The client’s cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client’s vital signs, the client says, “I think my bag of water just broke.” Which intervention would the nurse do first?
a. Check the status of the fetal heart rate.
b. Reassess the client’s vital signs.
c. Test the leaking fluid for fetal fibronectin.
d. Perform a sterile vaginal examination.
a. check the status of the fetal heart rate.
The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse’s first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord that inhibits fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to their right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. A vaginal examination may be appropriate once the status of the fetus has been evaluated. The nurse can continue to measure the client’s vital signs at routine intervals.
A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client’s partner of 5 years, whom the client has designated as health care power of attorney. The client’s children want their parent to be intubated. A nurse caring for this client knows that
a. clients commonly confer health care power of attorney on someone who shares their personal values and beliefs.
b, the client’s partner is responsible for national legislation regarding surrogate decision makers.
c, the children’s biological relationship with their parent supersedes the partner’s wishes.
d. health care providers must honor the children’s wishes to avoid a lawsuit.
a. clients commonly confer health care power of attorney on someone who shares their personal values and beliefs.
The health care power of attorney is someone who can make decisions when the client can’t. Clients tend to select individuals who share their personal values and beliefs as their health care power of attorney. Family members and designated surrogates don’t always agree; state laws regarding surrogate decision makers may differ. The legal rights of a health care power of attorney in regards to health care decisions supersede those of family members. The law designates the health care power of attorney as the person to make decision; violating this designation could result in a lawsuit.
Which finding in the client’s history would be the least likely to have predisposed the client to renal calculi?
a. having had several urinary tract infections in the past 2 years
b. having taken large doses of vitamin C over the past several years
c. drinking less than the recommended amount of milk
d. having been on prolonged bed rest after an accident the previous year
c. drinking less than the recommended amount of milk.
A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk.
Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation.
High daily doses of vitamins C are a risk factor because they can increase the citric acid level.
Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the bloodstream.
A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and the baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse’s most appropriate response to resolve this situation?
a. Contact the client’s partner to come home from work and immediately take the client to the emergency department.
b. Contact the client’s health care provider and the baby’s pediatrician.
c. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.
d. Ask the nursing student to stay with the client while the nurse performs the last home visit in the community.
c. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.
The nurse should contact the immediate nursing supervisor to clarify or guide the correct nursing actions in this acute mental health situation. Community mental health services may be available that could visit the home and assess and intervene in this situation. The nurse should help the birth parent and baby inside and stay with them until the supervisor advises how best to manage the situation. It is inappropriate to call the client’s partner and have them come home because the nurse first needs to assess and address any immediate safety concerns for the birth parent and baby. Asking the nursing student to remain with this client while the nurse leaves is inappropriate because this may jeopardize the safety of the nursing student. In addition, given the context, the care required may be beyond the nursing student’s scope of practice.
The parent of a newborn is voicing concerns about their baby’s ability to hear. What should the nurse tell the parent?
a. Newborns cannot hear well until they are at least 6 weeks old.
b. Their concern is unfounded because hearing problems are rare in newborns.
c. Most American states and Canadian jurisdictions mandate hearing tests for infants.
d. They can test the baby’s hearing by clapping their hands 24 inches (60 cm) from the infant’s head.
c. Most American states and Canadian jurisdictions mandate hearing tests for infants.
The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 states mandate screening, which is done by otoacoustic emissions or auditory brainstem response. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the parent’s concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12 inches.
After the nurse teaches the parent of an 18-month-old child being discharged with a prescription for co-trimoxazole about the medication, which statement by the parent would indicate the need for additional teaching?
a, “I’ll watch to see that they’re wetting their diapers as usual.”
b. “This medicine must be given on an empty stomach.”
c, “If they develop a sunburn-type rash, I’ll stop the medication and call my health care provider.”
d. “I’ll make sure they drink plenty of extra fluids.”
b. “This medicine must be given on an empty stomach.”
When co-trimoxazole is prescribed, it can be given on an empty stomach, but it can also be given with food or milk if it causes an upset stomach. Monitoring the child’s urinary output by observing the child’s diapers is important because diminished renal function is a possible adverse effect. The child needs to be monitored for Stevens-Johnson syndrome, a possible and serious adverse effect that causes a sunburn-type rash. If it develops, the medication should be withheld, and the health care provider should be notified. Drinking extra fluids is essential to promote adequate renal function for the child receiving a sulfa-type antibiotic.
A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should be the priority for the nurse to include in the teaching plan?
a. postoperative respiratory care exercises
b. nasogastric intubation and care
c. nutritional care during recovery
d. postoperative analgesia and pain control methods
a. postoperative respiratory care exercises.
The nurse must teach the client about respiratory care such as using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients do not have a nasogastric tube in place after a cholecystectomy. Teaching about nutritional care and pain control after surgery should be included, but would not be the priority.
A 4-year-old has just returned from surgery. The child has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, “I’m going to throw up.” What should the nurse do first?
a. Notify the health care provider because the child has an NG tube.
b. Immediately give the child an antiemetic IV
c. Irrigate the NG tube to ensure patency.
d. Encourage the parent to calm the child down.
c. Irrigate the NG tube to ensure patency
The nurse should first irrigate the NG tube because if the tube isn’t draining properly or is kinked, the child will experience nausea. There’s no reason to notify the health care provider immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn’t really address the problem. Encouraging the parent to calm the child is always a good intervention but isn’t the first thing to do in this case.