HURST REVIEW NCLEX-RN Readiness Exam 2 Solved 100%

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The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What ... actions demonstrate ethical nursing practice in the public health arena? - ANSWER 1. Speaking up for the underrepresented, such as the poor and uneducated persons 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located. Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? - ANSWER 1. Primipara needing assistance with breastfeeding. 3. Primipara who is two days post op cesarean section. A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? - ANSWER 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?" Which tasks would be appropriate for the nurse to assign to an LPN/VN? - ANSWER 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures. A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? - ANSWER 2. Begin treatment by inserting two large bore IVs of Normal Saline. The nurse is working at the triage station. Which client should the nurse triage first? - ANSWER 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? - ANSWER 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? - ANSWER 3. Client's last menstrual period was 8 weeks ago. The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? - ANSWER 3. Client who has a fractured hip. Which pediatric client should the nurse see first? - ANSWER 3. Three year old with wheezes in right lower lobe. What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? - ANSWER 3. Client's plan for transportation and care at home. A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? - ANSWER 1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen Which client must the nurse assign to a private room? - ANSWER 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) Which client requires immediate intervention by the nurse? - ANSWER 3. Client with a fractured femur reporting sharp chest pain of 4/10. Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? - ANSWER 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence. A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? - ANSWER 1. Ensure a do-not-resuscitate prescription has been provided. A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? - ANSWER 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take. - ANSWER Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? - ANSWER 2. Listen to the family's concerns and report those to the primary healthcare provider. A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? - ANSWER 4. Administer furosemide 20 mg intravenous push (IVP). A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? - ANSWER Blood pressure reading. A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? - ANSWER 1. Undergoing surgery for placement of a central venous catheter. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? - ANSWER 2. "I had rheumatic fever when I was 10 years old." A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? - ANSWER 2. Mammography 3. Influenza vaccine The primary healthcare provider suspects the client has tuberculosis (TB) and prescribes a Mantoux test. What precautions should the nurse take when administering the Mantoux test? - ANSWER 3. Wear a particulate respirator 5. Initiate airborne precautions. Which actions by the nurse, working in the recovery room, should be performed to prevent injury from a needle stick? - ANSWER 4. Replace the puncture resistant biohazard container when three-quarters full. 5. Use "needleless" devices whenever possible. The nurse is caring for a client while fluorouracil is being infused. The client reports burning at the intravenous (IV) site. What should the nurse do first? - ANSWER 4. Stop the infusion. A nurse has responded to the scene of a natural disaster to triage clients. Which client should the nurse triage with a black disaster tag? - ANSWER 2. 2nd and 3rd degree burns over 75 % of the body. The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure? - ANSWER 1. Face shield 3. Gown 4. Mask 5. Regular exam gloves A newborn in a neonatal unit is to receive penicillin G benzathine 50,000 units/kg intramuscularly (IM). The newborn weighs 6 lbs (2.7 kg). The dispensed dose is 25,000 units per 1 mL. What should the nurse do? - ANSWER 3. Consult with the pharmacy for a different medication concentration. A client is in the surgical suite to have a left total knee replacement. Prior to the surgeon initiating the first incision, what should the circulating nurse remind the surgical team to perform? - ANSWER 2. Time-out The unit charge nurse is responsible for reporting all healthcare associated infections. Which client condition needs to be reported? - ANSWER 1. A client diagnosed with Clostridium Difficile while receiving intravenous (IV) antibiotics. What is most important for the nurse to have at the client's bedside when inserting a large orogastric tube for rapid gastric lavage? - ANSWER 4. Suction equipment The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which action by the nurse indicates that further instruction on transmission of this disease is needed? - ANSWER 4. States that the newborn may contract herpes from the birth canal. A client with dementia has been admitted to the medical floor. The family informs the nurse that the client tends to wander at night. When planning client safety goals, which action by the nurse would take priority? - ANSWER 3. Designate an unlicensed assistive personnel (UAP) to sit with the client through the night. A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What statement made by the client indicates that teaching has been effective regarding safe needle disposal? - ANSWER 3. "I may use any hard plastic container with a screw-on cap." Which observations by the nurse indicate that a mother is protecting her two day old female newborn from infection? - ANSWER 1. Cleans perineum from front to back after newborn soils diaper. 2. Makes certain the umbilical cord remains dry with each diaper change. A nurse is planning a health education seminar for a group of females who are age 45-54. What should the nurse recommend be done annually? - ANSWER 2. Mammography 3. Influenza vaccine While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding? - ANSWER 1. Breech presentation Which finding should a nurse expect when assessing a healthy 65 year old client? - ANSWER 2. Presbyopia A nurse is instructing a client who had a cesarean birth 2 days ago about adverse signs that should be reported to the primary health care provider. Which signs should the nurse include? - ANSWER 1. Fever greater than 100.4° F (38° C) for 2 or more days. 3. Calves with localized pain, redness, and swelling. 4. Burning with urination. 5. Feeling of apathy toward newborn. The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? - ANSWER 4. Setting the alarm clock for medication times. What should a nurse teach a client who has been diagnosed with hepatitis A? - ANSWER 3. Symptoms of hepatitis A include malaise, dark colored urine, and jaundice. A nurse is planning to provide an education class on preconception health care to a group of young women wishing to become pregnant. What points should the nurse include in this class? - ANSWER 1. Attain a healthy weight. 2. Make sure immunizations are up to date. 3. Avoid drinking alcohol. 4. Learn family health history. The nurse is teaching parents of a school aged child about interventions to keep the child safe. Which interventions would be appropriate to include in the health promotion plan - ANSWER 1. Encourage bicycle helmet use when riding bikes. 2. Teach children to swim at an early age. 4. Keep firearms in the home locked and unloaded. 5. Teach "stop, drop, and roll" in case clothing catches on fire. The nurse is planning health promotion strategies for a single parent of young children who is trying to increase personal physical activity level but expresses a lack of time. Which interventions would help the client get more regular physical activity into the day? - ANSWER 1. Suggest walking up and down steps at home several times each morning and evening. 2. Suggest parking further away from the grocery store and work. 3. Walk with the children in the evening instead of watching TV with them. When assessing a client's testes, which finding would indicate to the nurse the need for further investigation? - ANSWER 3. Lump the size of a piece of rice. What should the nurse teach a pregnant client who comes to the clinic reporting hemorrhoids and constipation? - ANSWER 1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. The client needs more fiber in the diet. 5. The client needs to increase fluid intake. The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include? - ANSWER 3. Intravenous administration of isotonic saline. During evening rounds, the nurse discovers that a violent client with a history of threats against a former girlfriend cannot be located. The client's window is open and personal belongings missing. Based on recent threats of violence against the girlfriend, what is the nurse's initial action? - ANSWER 3. Initiate the missing client protocol. The nurse is teaching a class to primiparas on breastfeeding. How many extra kilocalories per day would the nurse instruct the class participants to consume post-delivery to compensate for the increased energy requirements of lactation? - ANSWER 3. 500 A client who has been on a psychiatric unit because of several attempted suicides states, "I am happy to be going home today." What is the nurse's best analysis of this statement? - ANSWER 3. May have decided on another suicide plan. A teenage client is placed on life-support as a result of a motor vehicle accident (MVA). Following an electroencephalogram (EEG), the client has been declared brain dead. Which action by the nurse would take priority? - ANSWER 3. Contact the regional organ procurement team. A nurse is attempting to develop trust with a psychiatric client exhibiting concrete thinking. Which nursing intervention would promote trust in this individual? - ANSWER 1. Attend an activity with the client who is reluctant to go alone. 3. Consider client preferences when possible in decisions concerning care. 4. Provide a blanket when the client is cold. 5. Provide food when the client is hungry. The occupational health nurse is leading a group discussion about addiction. What should the nurse include as the primary barrier to the client with alcohol addiction seeking treatment? - ANSWER 2. Denial The nurse is planning daily activities for a client who has a diagnosis of schizophrenia. The client tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for this client? - ANSWER 3. Spending time in brief one on one interactions with the nurse. A parent tells the clinic nurse, "My child has just been diagnosed with attention-deficit/hyperactivity disorder (ADHD). What will be done to help my child?" How should the nurse best respond to the parent? - ANSWER 4. The standard of care for children with ADHD includes central nervous system stimulants along with behavior and family therapy. A home care nurse is preparing to perform venipuncture to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What should be the nurse's first action? - ANSWER 3. Decrease stimuli in the room. A client is seen in the clinic for recurrent unexplained, vague stomach pain over the past 5 years. EGD, colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the symptoms. The client tells the nurse, "The doctor thinks the pain in my stomach is psychosomatic. But the pain is so bad some times that I can't function!" What is the nurse's most appropriate response? - ANSWER 1. "The pain you feel is real." [Show More]

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