Questions and Answers
In what position should the nurse place a client diagnosed with gastric reflux?
What statement by the client would indicate to the nurse that further teaching is needed regarding a gluten-free diet?
Which food items would indicate to the nurse that the UAP understands a clear liquid diet? (Select all that apply)
Which electrolyte imbalance would be the nurse's priority concern for a client with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism?
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Following three days of treatment, what information should the nurse include in discharge teaching for a client with encephalopathy secondary to cirrhosis? (Select all that apply)
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What actions should the nurse take for a client who reports dizziness and weakness while walking? (Select all that apply)
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Which finding would indicate a possible complication after an endoscopic retrograde cholangiopancreatogram (ERCP)?
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What is the first nursing action for a client with suspected tuberculosis?
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After a heart catheterization, what should be the nurse's first action for a client with severe foot pain on the side of the femoral insertion site?
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Which interventions would help control a client's pain following an acute abdominal situation? (Select all that apply)
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What priority action should the nurse perform after a lumbar puncture when the client reports a headache on a pain scale of 8 out of 10?
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Which action by a UAP should the nurse interrupt while caring for a client with a skull fracture?
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Why is metoprolol likely to decrease chest pain episodes for a client with a history of CHF switching from hydralazine?
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What additional findings would make the nurse suspect pancreatitis in a client with a history of alcoholism? (Select all that apply)
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What statement by a client indicates successful teaching for preventing urinary tract infections? (Select all that apply)
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Which statement indicates understanding of the nurse's teaching about an upper GI series?
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What nursing interventions would be appropriate for a client with end-stage chronic renal failure exhibiting dry, itchy skin and uremic halitosis? (Select all that apply)
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What early warning signs of Alzheimer's Disease (AD) should the nurse include in teaching? (Select all that apply)
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Which signs or symptoms would indicate a client needs further investigation during a cancer risk screening? (Select all that apply)
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What intervention should the nurse initiate first for a post-operative client who becomes anxious and reports acute chest pain?
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Which risk factors for influenza complications would be included in a session about influenza? (Select all that apply)
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What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? (Select all that apply)
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Which potential side effect should the nurse educate the client regarding while receiving spironolactone?
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Which teaching points should the nurse include about foot and leg care for a client diagnosed with peripheral vascular disease (PVD)?
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What assessment finding would the nurse expect to see in a client diagnosed with Guillain-Barre' Syndrome?
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When dressing a severe burn on the right hand, what is important for the nurse to do?
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What statement indicates that the client understands the edrophonium (Tensilon) test?
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Following burns to the chest and legs, which assessment should the nurse perform immediately?
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What is the priority nursing action for a client with tingling of the toes and feet following the flu who begins to have numbness in the legs and hips?
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A client reports excruciating paroxysmal facial pain. What disorder does the nurse suspect?
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In the case of critical lab results, which body system requires immediate notification of the healthcare provider?
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What is the priority action by the nurse for a client with a bypass graft of the left femoral artery who develops left leg pain and coolness?
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What should be included in the discharge teaching plan for a client with lymphedema post right mastectomy?
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Which dietary changes should be included in teaching for a client with iron deficiency anemia?
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What should the nurse advise a 68-year-old client experiencing tremors?
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What change would best indicate improvement in a client receiving chemotherapy for breast cancer?
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What symptoms reported by the client with benign prostatic hyperplasia (BPH) indicate medications are not working?
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Which client complaint concerning systemic scleroderma should be of most concern to the homecare nurse?
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Which measures can caregivers take to reduce the risk of falls in their elderly parent?
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What is the highest priority goal for a client after total hip replacement?
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What is the best indicator of the effectiveness of an escharotomy after a circumferential burn?
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For a major burn, which evaluation of fluid resuscitation is most effective in the first 24 hours?
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What provides the most accurate information regarding diet for a client with advanced cirrhosis?
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Which signs and symptoms validate the nurse's suspicions of a cholinergic crisis in a myasthenia gravis client?
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What is the most significant assessment finding in a client with acute coronary syndrome?
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What intervention should the nurse implement for a graft site within the first 24 hours?
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What interventions should be included for clients to prevent and treat fungal infections of the feet?
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Which assessment finding is most indicative of fluid volume overload?
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What therapeutic statement should the nurse make to an elderly client afraid of falling when first ambulating post-hip replacement?
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What should the nurse do first for a client showing decreased consciousness and vital sign changes post-CABG?
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Which laboratory results provide evidence of diabetes insipidus?
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What action should the nurse take if constant bubbling is noted in the water seal chamber of a chest tube two days post-insertion?
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Which findings should be expected in elderly clients regarding nutrition?
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What should the nurse do first for a client with acute myeloid leukemia experiencing pain from mucositis?
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What is the nurse's priority action upon finding an unfamiliar client standing in a puddle of liquid?
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Which observation indicates a serious complication for a client with a closed head injury?
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Which statements from teenage girls indicate effective teaching on breast self-awareness?
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Which meal option should the client diagnosed with gout select?
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What score should be assigned to a client assessed using the Braden Scale?
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What acid-base imbalance do the lab values indicate to a nurse for a newly admitted client?
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Study Notes
NCLEX Practice Questions - Adult Health Study Notes
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Primary Hyperaldosteronism and Spironolactone
- Potential side effects include erectile dysfunction, gastrointestinal upset, and gynecomastia.
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Peripheral Vascular Disease (PVD) Teaching
- Foot and leg care recommendations: Wear soft cotton socks, avoid hot whirlpools, and clear pathways in the house.
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Guillain-Barre Syndrome Findings
- Expected assessments include areflexia, dysphagia, and orthostatic hypotension.
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Burn Care
- Wrap each digit individually when dressing a hand burn to prevent webbing.
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Edrophonium (Tensilon) Test
- Client should understand that repetitive movements will be tested after the medication is administered.
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Emergency Assessment after Burns
- Immediate priority assessment is airway integrity for clients with burns.
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Numbness after Flu Illness
- Priority action is to notify the primary healthcare provider due to potential complications.
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Facial Pain Diagnosis
- Excruciating, paroxysmal facial pain after cold exposure suggests trigeminal neuralgia.
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Laboratory Results and Urgent Issues
- Critical renal changes require immediate notification to the healthcare provider.
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Postoperative Complications - Leg Pain
- In a patient post-femoral artery bypass, notify the healthcare provider if leg pain and coolness occur.
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Lymphedema Teaching Post-Mastectomy
- Recommendations include using a thimble for sewing, wearing heavy oven mitts, long sleeves to prevent insect bites, and using an electric razor.
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Iron Deficiency Anemia Education
- Emphasize iron-rich foods, report any symptoms like glossitis, and educate on ferrous sulfate supplements.
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Tremors in Elderly Clients
- Report tremors to the primary health care provider due to potential underlying issues.
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Cancer Treatment Management
- Weight gain after chemotherapy indicates improvement in the client's condition.
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Impact of Benign Prostatic Hyperplasia Medications
- Symptoms indicating treatment failure include bladder pain, urinary frequency, and terminal dribbling.
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Scleroderma Concerns
- Difficulty swallowing is a significant concern for clients with scleroderma.
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Fall Prevention in Elderly
- Key strategies include ensuring adequate lighting, using contrasting colors for stairs, and installing grab bars.
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Post-Total Hip Replacement Care
- Highest priority goal is to prevent respiratory complications.
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Escharotomy Evaluation
- Prompt capillary refill under 2 seconds after blanching indicates effectiveness of the procedure.
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Burn Fluid Resuscitation Monitoring
- Effective resuscitation is indicated by urine output of 860 mL within 24 hours.
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Dietary Limitations in Cirrhosis
- Protein intake must be restricted due to elevated ammonia levels in cirrhosis patients.
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Cholinergic Crisis Signs
- Validation of crisis includes symptoms such as diarrhea, increased urination, and nausea or vomiting.
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Acute Coronary Syndrome Monitoring
- Ventricular fibrillation is the most significant finding during continuous cardiac monitoring.
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Management of Grafted Sites
- Position the arm to prevent pressure on the graft site within the first 24 hours post-surgery.
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Fungal Infection Prevention for Feet
- Wash feet daily, apply terbinafine cream, wear breathable shoes, and use shower sandals in public places.
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Fluid Volume Overload Indicators
- Pitting edema in lower extremities is indicative of fluid volume overload.
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Therapeutic Communication for Elderly
- Encourage discussions about fears or worries regarding ambulation to promote a supportive environment.
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Post-Surgery Complications Following CABG
- Administer 100% oxygen immediately for decreased level of consciousness and vital signs indicating shock.
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Diabetes Insipidus Indicators
- Urine specific gravity of 1.004 and elevated serum sodium levels are indicative of diabetes insipidus.
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Chest Tube Observations
- Constant bubbling in the water seal chamber after chest tube insertion necessitates notifying the healthcare provider.
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Elderly Nutrition Assessments
- Dental problems, decreased appetite, and varying caloric needs are common in elderly clients.
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Acute Myeloid Leukemia Pain Management
- Administer pain medication first for clients experiencing pain from mucositis.
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Priority Actions for New Clients in Long-Term Care
- Ensure the safety of clients by addressing any spills immediately.
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Serious Complications in Head Injuries
- Report a petechial rash with a temperature increase as it may indicate a serious condition.
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Effective Breast Self-Awareness Teaching
- Statements regarding monthly self-exams and recognizing warning signs indicate effective education.
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Systemic Lupus Erythematosus Flare-Up Signs
- Abdominal discomfort, alopecia, and butterfly rash are common indicators of SLE flares.
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Dietary Selection for Gout
- Choose options such as vegetable soup, whole wheat toast, and skim milk to manage gout.
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Portosystemic Encephalopathy Neurological Deterioration
- Elevated ammonia levels (80 mcg/dl) are likely responsible for neurological symptoms.
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Prednisolone Monitoring in Nephrotic Syndrome
- A weight gain of 2 lbs in 24 hours is a priority concern and should be addressed immediately.
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Alzheimer's Disease Care Planning
- Focus on assessing self-care abilities, breaking tasks into manageable steps, and providing companionship through communication.### Card Assessments and Interventions
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Prioritize assessment findings post-total hip replacement, focusing on a temperature of 101.8°F (38.7°C) due to potential infection risk.
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For a patient with diverticulosis, correct dietary selections include avocados, acorn squash, lima beans, and raspberries, indicating understanding of prescribed dietary modifications.
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In suspected pancreatitis, additional concerns include Cullen's Sign and tachycardia in a patient with severe abdominal pain and a history of alcoholism.
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A burn victim's area that is pale but has good capillary refill necessitates keeping the room warm to promote blood flow.
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Indicators of a tension pneumothorax include tracheal deviation and dyspnea.
Nutritional Education and Dietary Considerations
- Post-gastric bypass symptoms like dizziness can be alleviated by reducing carbohydrate intake, eating small meals, and sitting semi-recumbent during meals.
- Signs of diabetic ketoacidosis in a patient may include dry mucous membranes, fruity breath, and glycosuria.
- In educating adults about essential foods for vitamin B12 intake, emphasize calf liver, feta cheese, shrimp, and tuna.
Patient Education and Risk Assessments
- Palliative care focuses on symptom management and improving quality of life, not solely on curative measures.
- For a postmenopausal client, combined low doses of estrogen and progestin may be recommended for hormonal therapy, especially when a uterus is present.
- Assessing for home safety should include ensuring fire safety measures are in place, such as fire extinguishers on each level and testing smoke alarms monthly.
Health Risks and Monitoring
- Recognize the increased risk of aspiration pneumonia in stroke survivors with a history of GERD, characterized by lethargy and facial droop.
- Educate about heart health by emphasizing daily weight checks and the elimination of alcohol in patients with liver issues after discharge.
- Monitor for potential complications post-ERCP, especially if the patient reports significant abdominal pain.
Special Considerations for Conditions
- For clients with conditions like multiple sclerosis, expect symptoms such as fatigue, ptosis, blurry vision, and electrical sensations while bending the neck.
- Individuals diagnosed with idiopathic thrombocytopenic purpura (ITP) are likely to experience bleeding gums, ecchymosis, and petechiae.
- In cases of hypomagnesemia following chronic alcoholism, prioritize the identification of the electrolyte imbalance affecting the patient.
Client Management in Critical Situations
- After intubation of a client, assess bilateral breath sounds as a priority action before securing the endotracheal tube or obtaining an x-ray.
- In evaluating a client recovering from a stroke and presenting with homonymous hemianopia, place their meal on the unaffected side for ease of access.
- During a nursing assessment of a client with suspected tuberculosis, prompt identification of symptoms should occur alongside isolation procedures.
Understanding Dietary Restrictions
- Educate clients with celiac disease that they can’t consume wheat products, emphasizing a strict gluten-free diet while dispelling misconceptions about other foods.
- In coaching a client recovering from a thyroidectomy, ensure the avoidance of nuts such as roasted almonds due to potential complications in recovery.
- Guide clients on clear liquid diets by identifying acceptable options like white grape juice, gelatin, and broth, while correcting misunderstandings about pudding and other non-clear items.### Pain Management and Interventions
- Abdominal pain with rigidity indicates potential severe conditions; interventions include NG tube suction, side-lying position, and PCA pump for hydromorphone.
- Frequent small feedings are not prioritized for acute pain management.
Post-Lumbar Puncture Care
- Severe headaches post-lumbar puncture should be managed by placing the client in a supine position to alleviate pressure.
Client Care with Skull Fracture
- UAP actions should be monitored; assisting with turn, cough, and deep breathing is inappropriate for clients with skull fractures due to risk of increased intracranial pressure.
Medications in Heart Failure Management
- Switching from hydralazine to metoprolol addresses reflex tachycardia, reducing chest pain episodes in clients with congestive heart failure.
Pancreatitis Indicators
- Clients with severe abdominal pain and a history of alcoholism presenting with umbilical bruising, fever with tachycardia, and back-radiating pain may indicate pancreatitis.
Urinary Tract Infection Prevention
- Effective prevention strategies include timely urination, hydration, dietary acidity enhancement, and proper hygiene practices.
Understanding Upper GI Series
- Knowledge of upper GI series includes consuming contrast material for x-ray imaging, essential for accurate diagnosis.
Chronic Renal Failure Management
- Nursing care for clients with chronic renal failure involves skin care with emollients, wearing cotton gloves at night, cutting fingernails, and oral hygiene.
Early Signs of Alzheimer's Disease
- Key early warning signs include mild disorientation and difficulties with words and numbers, essential for caregivers to recognize.
Cancer Risk Screening Indicators
- Symptoms suggesting a need for further investigation include leukoplakia, prolonged hoarseness, hematuria, and persistent abdominal bloating.
Acute Post-Operative Care
- In cases of acute chest pain and shortness of breath, raising the head of the bed is a critical first intervention to improve respiratory function.
Influenza Risk Factors
- High-risk groups for influenza complications include individuals over 65, those with diabetes, renal disease, and residents of nursing homes.
Smokeless Tobacco Education
- Education for teens on smokeless tobacco should emphasize regular oral inspections, reporting of lesions, and cessation strategies, as it poses health risks.
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