NCLEX Prep 2

The nurse is performing an initial assessment on a newborn infant. When assessing the infant’s head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?

• Document the findings.

• Arrange for hearing testing.

• Notify the health care provider.

• Cover the ears with gauze pads.

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

• The nail beds

• The skin in the sacral area

• The skin in the abdominal area

• The membranes in the ear canal

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan?

• Ensure that the knots are at the pulleys.

• Check the weights to ensure that they are off of the floor.

• Ensure that the head of the bed is kept at a 45- to 90-degree angle.

• Monitor the weights to ensure that they are resting on a firm surface.

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client’s health. Which interventions are appropriate? Select all that apply.

• Set the room temperature at a comfortable level.

• Remove distracting objects from the interviewing area.

• Place a chair for the client across from the nurse’s desk.

• Ensure comfortable seating at eye level for the client and nurse.

• Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).

The nurse is caring for an older adult who has been placed in Buck’s extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

• Apply restraints to the client.

• Ask the family to stay with the client.

• Place a clock and calendar in the client’s room.

• Ask the laboratory to perform electrolyte studies.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?

• Urinary incontinence

• Signs of skin breakdown

• The presence of bowel sounds

• Signs of infection around the pin sites

The nurse is caring for a client scheduled for a transphenoidal hypophysectomy. The preoperative teaching instructions should include which most important statement?

• "Your hair will need to be shaved."

• "You will receive spinal anesthesia."

• "You will need to ambulate after surgery."

• "Brushing your teeth will not be permitted for at least 2 weeks after surgery."