UWORLD – NCLEX RN
1. The nurse receives the hand off shift report on assigned clients. Which information is most concerning and prompt nurse to assess that client first?
a. Client 1 day post colon resection who is receiving continual epudural morphine and reports severe itching (A histamine rel...
a client taking morphine sulfate for acute pain ha
Written for
Massachusetts Institute Of Technology
NURSING 563 (NURSING563)
All documents for this subject (20)
Seller
Follow
docguru
Reviews received
Content preview
UWORLD – NCLEX RN
1. The nurse receives the hand off shift report on assigned clients. Which information is
most concerning and prompt nurse to assess that client first?
a. Client 1 day post colon resection who is receiving continual epudural morphine and
reports severe itching (A histamine related reaction (eg puritis) is an expected
adverse effect associated with the administration of epidural morphine)
b. Client admitted 2 hours ago with gastroenteritis who has been vomiting for 36
hours and has muscle cramps and weakness
c. Client who has received IV bumetamide for 3 days for heart failure and
experiences dizziness when standing up (excessive diuresed could have caused the
orthostatic hypotension)
d. Client with acute poststreptococcal glomerulonephritis who is receiving antibiotics
and has gross hematuria (Gross hematuria is an expected manifestation of 1. The nurse is preparing to infuse 2 units of packed red blood cells (PRBC) to a client
poststreptococcal glomerulonephritis. It is usually mild and does not require with gastrointestinal bleed. Which actions should the nurse take? Select all that apply
urgent attention) a. Assess clients vital signs
** The nurse should assess first he newly admitted client with gastroenteritis as b. Infuse both units simultaneously
prolonged vomiting increases risk of dehydration, acid base and electrolyte c. Obtain a Y tubing set and prime with normal saline (NS)
disturbance (eg. Orthostatic hypotension, acid loss, hypokalemia, hynatremia) d. Plan to remain with client during the 1st 15 minutes of transfusion
e. Set infusion pump to deliver unit over 30 to 45 minutes
1. A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse f. Spike filtered intravenous (IV) tubing with dextrose 5% water (D5W)
suspects the client has developed urinary retention. What is the priority nursing
intervention? 1. Obtain a unit from blood from the blood bank and verify the blood product with
a. Ask if the client neds to use the bedpan (does not aid in the assessment of urinary type and crossmatch results and at least 2 client identifiers with another nurse at the
retention) clients bedside.
b. Assess the client’s fluid intake (assess for fluid intake after assessing bladder 2. Assess the client, obtain vital signs for baseline, and teach sings of a transfusion
distention) reaction and how to call for help
c. Assess the clients skin turgor (last to do) 3. Use a Y tubing, prime with NS, and then clamp the NS side
d. Palpate the client’s suprapubic area 4. Spike the blood product, leaving the blood side of the Y tube open while keeping
the salin side clamped for infusion. The saline is only to prime the tubing and flush
** Morphine sulfate, anticholinergic medications, and tricyclic anti-depressants can after the infusion. It does not infuse simultaneously
cause urinary retention, they increase bladder sphincter tone and or relax bladder 5. Set the infusion pump to deliver blood over 2-4 hours as prescribed. Rapid infusion
muscle of the blood puts the client at greater risk for transfusion reaction and fluid volume
1. The nurse caring for a client with pulmonary edema responds to the mechanical overload
ventilator high pressure alarm. The nurse would assess for which conditions that can 6. Remain with the client for at least the 1st 15 minutes and watch for signs of blood
trigger the high pressure alarm? transfusion reaction, including fever, chills, nausea, vomiting, pruritus,
a. Biting endotracheal tube hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion
b. Disconnected ventilator tubing immediately if a reaction occurs. The first 15 minutes of infusion should be slow to
c. Endotrachael tube cuff leak watch for these reactions
d. Excessive airway secretions 7. Take another set of vital signs 15 minutes after infusion starts and continue in
e. Kinked ventilator tubing accordance with facility policy.
8. On completion of the blood transfusion, open the saline side clamp of the Y tubing
to flush all blood in the tubing through with NS
, 9. Return the blood bag with the attached set up tp the laboratory after completion or
dispose of in accordance with hospital policy. Use new IV Y tubing set up for the
second unit of blood
1. The office nurse, while reviewing a clients health information, notices that the client
has recently started taking St. John’s wort for symptoms of depression. What
additional information is most important for the nurse to obtain?
a. Ask if the client is currently taking any prescription antidepressant
medication
b. Ask if the client has been diagnosed with depression by a mental health care
provider
c. Ask if client takes a multivitamins with iron
d. Ask if client uses tanning beds
** St. john’s wort is an herbal product commonly used by many clients to treat
depression. However, it may interact with medications used to treat depression or
other mood disorder, including tricyclic antidepressant, selective serotonin and or 1. The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr
norepinephrine receptor inhibitors and monoamine inhibitors. for a client who has a pulmonary embolus and weighs 198lb. The infusion bag
contains 25,000 units of heparin in 500mL of D5W. At what rate in milliliters per
1. A home health nurse is giving an infection control presentation on pulmonary hour (mL/hr) does the nurse set the IV infusion pump? Record your answer using a
tuberculosis (TB) disease to a group of home health aides. Which statement made by whole number.
a home health aide indicates an understanding about the mode of transmission of
pulmonary TB?
a. It is spread by contact with the clients blood or urine
b. It is spread by contact with the clients soiled clothing and bed linens
c. It is spread by contact with the clients soiled eating utensils
d. It is spread by small droplets that the client cough or sneezes into the air
1. After a client with Alzheimers disease is found wandering in the middle of the street
at 3:00AM and returned by police, the community health nurse teaches family
members about measures to keep the client safe at home. What is the most important
strategy for the nurse to include in the instruction?
a. Ensure that the client is never left alone
b. Notify neighbors of the clients tendency to wander
c. Place a chain lock on the door above or below the clients eye level
d. Place a safe return bracelet on the clients non dominant hand
1. The nurse is caring for a client with suspected pelvic inflammatory disease (PID).
When the nurse is obtaining the clients health history, which of the following
questions would provide pertinent data about the clients risk factors for PID? Select
all that apply
a. Are you currently taking oral contraceptive?
b. At what age did you experience your first menstrual cycle?
c. Do you engage in sexual intercourse with multiple partners?
d. Have you ever been diagnosed with a sexually transmitted infection?
e. Have you recently had an abortion or pelvic surgery?
,2. A client with chronic stable angina is reporting chest pain. The nurse notices that the 1. The nurse is reviewing new prescriptions for assigned clients. Which prescription
transdermal nitroglycerin patch that was applied 1 hours ago has peeled off. The would require further clarification from the health care provider?
clients vital signs are stable. What is the nurses priority action? a. Alteplase for an ischemic stroke in a client with a blood pressure of
a. Administer PRN morphine 1925/112mmHg
b. Administer PRN sublingual nitroglycerin b. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant
c. Apply new transdermal nitroglycerin patch c. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy
d. Obtain a 12 lead electrocardiogram to cdeine
d. Sodium chloride 3% infusion for a client with syndrome of inappropriate
** Angina is chest pain due to myocardial ischemia. A client with chronic stable antidiuretic hormone
angina experiences intermittent chest pain relieved with rest or administration of
nitroglycerin. ** Thrombolytic agents (eg alteplase, Tenecteplase, reteplase) place clients at risk for
bleeding. Therefore, they are contraindicated in clients with active bleeding, recent
Transdermal nitroglycerin patches have a delayed onset of action (40-60 minutes) trauma, arteriovenous malformation, history of hemorrhagic stroke, and
and are not effective in the treatment of acute anginal pain. If a patch is uncontrolled hypertension.
accidentally removed, a new one may be applied after the nurse fist administers
sublingual nitroglycerin. 1. A nurse working in the office of a health care provider receives 4 telephone
messages. Which client call should the nurse return first?
1. The nurse is caring for a client with gestational diabetes mellitus during the second a. Client with acute sinusitis prescribed azithromycin 3 days ago now has hives
stage of labor. After birth of the head, the nurse notes retraction of the fetal head b. Client with chronic low back pain requests an oxycodone medication prescription
against the maternal perineum. Which action should the nurse anticipate? refill
a. Administering a tocolytic c. Client with fever of 100F (37.7C) has aching and itching at site after getting a flu
b. Initiating fundal pressure during a contraction shot yesterday
c. Obtaining the vacuum extractor d. Client with newly diagnosed asthma has palpitations after using an albuterol rescue
d. Pressing downward on the symphysis pubis inhaler
** Shoulder dystocia is an obstetrical emergency in which the fetal had emerges but ** Hives can be a manifestation of hypersensitivity to the macrolide antibiotic
the anterior shoulder remains wedged behind the maternal symphysis pubis. The azithromycin
nurse may initially observe the fetal head retracting back towards the maternal
perineum after birth of the head. 1. An infant is experiencing respiratory depression immediately after a vaginal delivery
using epidural analgesia with morphine. The health care provider prescribes
1. The emergency nurse is admitting a 12 year old client who reports palpitations. 0.1mg/kg naloxone IM to be given STAT once. The client weighs 3600 grams and
Which action should the nurse anticipate? Click the exhibit button for additional naloxone 0.4mg/mL is available. How many milliliters will the nurse administer?
information Record your answer using one decimal place
a. Adminsitering epinephrine by rapid IV push
b. Assisting the client to a tripod position
c. Instructing the client to hold their breath and bear down
d. Sedating the client for immediate asynchronous defibrillation
** Supraventricular tachycardia (SVT) is the most common tachyarrhythmia of
childhood and refers to a rapid heart rate of 200-300/min with no variation in rate
during activity.
, d. Vitamin D
e. Vitamin K
2. The nurse is performing an assessment on a neonate shortly after delivery. The nurse 1. The health care provider prescribes phenazopyridine hydrochloride with a urinary
is most concerned about which assessment finding? tract infection. What would the office nurse teach the client to expect while taking
a. Bialteral rales found on lung auscultation this medication?
b. Dullness over bladder found on percussion a. Constipation
c. Ptosis of right eyelid found on facial inspection b. Difficulty sleeping
d. Single testicle found on genital palpation c. Discoloration of urine
d. Dry mouth
** Eyelids should sit above the pupils symmetrical with irises showing. Ptosis
(drooping of the eyelid below the level of the pupil) could indicate paralysis of the ** Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to
oculomotor nerve. relieve the pain and burning associated with a urinary tract infection.
1. When caring for a client with a left radial artery catheter, which assessment data 1. The nurse receives report on 4 clients. Which client should be seen first?
obtained by the nurse indicates the need to take immediate action? a. 10 month old with audible congestion and mucus producing cough
a. Capillary refill less than 3 seconds b. 10 year old with an active nose bleed who is applying pressure
b. Left hand cooler than right c. 12 year old with urinary frequency and burning and fever
c. Mean arterial pressure of 65mmHg d. 15 year old with painful right hip, fever, and limited range of motion
d. Pressure bag at 300mmHg
**The client is experiencing localized (pain, limited range of motion) and systemic
1. A nurse is giving instruction s related to antibiotic eye drops to the parent of a 5 year infection symptoms (fever) which may indicate septic arthritis.
old with bacterial conjunctivitis. Which instruction is most important? 1. The nurse is caring for a client who develops Clostridium difficile colitis after
a. Discard tissue used to blot excess medication from the eye immediately multiple days of antibiotics therapy. Which infection control measures are
b. Have your child lie down before you instil the eye drop appropriate to implement? Select all that apply
c. Use warm, moist compresses to remove crusting on eyelids a. Disinfect surfaces with diluted bleach solution
d. Wash hands before and after eye drop instillation b. Hand hygiene with alcohol based hand rub
c. Wear a face mask
1. The nurse is an outpatient clinic is caring for a client with addisions disease who has d. Wear a face mask
been taking hydrocortisone 20mg daily for the last 8 years. Which client data is most e. Wear a protective gown
important to report to the health care provider? f. Wear nonsterile gloves
a. Blood pressure of 140/90mmHg
b. Low grade fever of 100.4F (38C) 1. The emergency nurse is triaging clients. Which report is most concerning and would
c. Mild increase in fasting blood glucose be given priority for definitive diagnosis and care?
d. Weight gain of 6lb (2.7kg) in 3 months a. Abrupt, tearing, moving (upper to lower) back pain and epigastric pain
** Addison disease (primary adrenocortical insufficiency) is characterized by a b. Severe lower back pain after lifting heavy boxes
deficiency in all three types of adrenal steroids, most commonly caused by an c. Sharp calf ache with ambulation that improves with rest
autoimmune response. Corticosteroids therapy (hydrocortisone, dexamethasone, d. Unilateral leg swelling with 2+ pitting edema after an airplane trip
prednisone) is the primary treatment for Addison disease. ** Aortic dissection occurs when the arterial wall intimal layer tears and allows blood
1. The nurse is reinforcing discharge teaching for the parents of a 1 year old with a newly between the inner (intima) and middle (media) layers. Clients with ascending aortic
diagnosed cows milk allergy. Which nutrients normally provided by milk should be dissections typically have a chest pain, which can radiate to the back.
obtained from other sources? Select al that apply
a. Calcium
b. Fiber
c. Iron
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller docguru. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.99. You're not tied to anything after your purchase.
