NCLEX Select All That Apply Übungsprüfung 7
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
Please select 2 correct answers
“I should empty my ostomy pouch of urine when it is full.”
A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.
Please select 4 correct answers
Please refer to the text mode for the rationale.
A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)?
Please select 2 correct answers
The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.
A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.
Please select 5 correct answers
When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.
When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.
Please select 3 correct answers
In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
Please select 4 correct answers
A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.
To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.)
A small glass of milk relaxes the body and promotes sleep.
The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply):
Please select 3 correct answers
These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.
The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):
Please select 2 correct answers
Research demonstrate that the occurrence of SIDS is reduced with these two positions.
A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal?
Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol. Answer A is incorrect because methodone is given to the client withdrawing from opiates. Answer C is incorrect because naloxone is an antidote for narcotic overdose. Answer D is incorrect because disufiram is used in aversive therapy for alcohol addiction.
A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:
The client’s breakfast should be served within 30 minutes to coincide with the onset of the client’s regular insulin.
A 10-year-old has an order for Demerol (meperidine) 35 mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?
The nurse should administer 0.7mL of the medication. Answers A, B, and D are incorrect because the dosage is incorrect.
Which antibiotic is contraindicated for the treatment of infections in infants and young children?
Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development. Answers B, C, and D are incorrect because they can be used to treat infections in infants and children.
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
The client with echolalia repeats words or phrases used by others. Answer A is incorrect because it refers to clang association. Answer C is incorrect because it refers to circumstantiality. Answer D is incorrect because it refers to neologisms.
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
Holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness of the hands. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
The infant’s birth weight should double by 6 months of age. Answers B, C, and D are incorrect because they are greater than the expected weight gain by 6 months of age.
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