nclex study- AR

Front

What is the appropriate sequence to teach a client for collecting a clean catch urine specimen?

Back

Clean the meatus, begin voiding, then catch urine stream.

Front

Following change-of-shift report on an orthopedic unit, which client should the nurse see first? 16 year-old who had an open reduction of a fractured wrist 10 hours ago, 20 year-old in skeletal traction for 2 weeks since a motor cycle accident, 72 year-old recovering from surgery after a hip replacement 2 hours ago, 75 year-old who is in skin traction prior to planned hip pinning surgery.

Back

72 year-old recovering from surgery after a hip replacement 2 hours ago

Front

A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Back

Glascow Coma Scale 8, respirations regular

Front

When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

Back

Prothrombin time

Front

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

Back

Administer the prn dose of albuterol.

Front

A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? The client‘s urine output was 1500 cc in 5 hours.

Back

The client‘s urine output was 1500 cc in 5 hours.

Front

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) a report of 10 pounds weight loss in the last month B) a comment by the client "I just can't sit still." C) the appearance of eyeballs that appear to "pop" out of the client's eye sockets D) a report of the sudden onset of irritability in the past 2 weeks

Back

the appearance of eyeballs that appear to "pop" out of the client's eye sockets

Front

The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately? A) prolonged inspiration with each breath B) expiratory wheezes that are suddenly absent in 1 lobe C) expectoration of large amounts of purulent mucous D) appearance of the use of abdominal muscles for breathing

Back

expiratory wheezes that are suddenly absent in 1 lobe

Front

A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?

Back

Assessing the client's ability to participate in self care and/or the reliability of a caregiver.

Front

A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to

Back

Administer epinephrine 1:1000 as ordered.