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NURSING MISC NCLEX Exam 2_Study Guide. Questions and Answers: Complete Guide for a GRADE BOOST

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8... [Show More] mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? Temperature The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. Feeling cold, Loss of body hair, Persistent lethargy, Puffiness of the face A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? Respiratory distress A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. Fever, Nausea, Tremors, Confusion The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high-fiber foods in the diet Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? "Usually these physical changes slowly improve following treatment." The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? To treat hypocalcemic tetany A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? Take a blood glucose test before exercising. The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. A thyroid-releasing inhibitor will be prescribed, Encourage the client to consume a wellbalanced diet. A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? The client needs immediate education before discharge A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? "Let me go over the types of insulins with you again." A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? Glucagon A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? Regular insulin via the intravenous (IV) route The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? Positive Trousseau's sign The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? Increased thirst The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? Increased production of glucose The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? Severe abdominal pain Eye The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? Eye medications will need to be administered for life. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? A sense of a curtain falling across the field of vision The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? Blurred vision The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. Avoid activities that require bending over, Take acetaminophen for minor eye discomfort, Place an eye shield on the surgical eye at bedtime, contact the surgeon if a decrease in visual acuity occurs Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? Note the time of day the test was done A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? Instruct the client that he or she may need glasses when driving A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? Cardiovascular disease A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? Placing an eye patch over the client's affected eye The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? Client report of tunnel vision The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? "The hearing aid should not be worn if an ear infection is present." The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions should the nurse take when performing the irrigation? Select all that apply. Position the client with the affected side down after the irrigation, Warm the irrigating solution to a temperature that is close to body temperature, Position the client to turn the head so that the ear to be irrigated is facing upward, Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse should prepare to instruct the client's spouse in which measure that will facilitate communication? Speak in a normal tone and face the client when speaking. A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? Instillation of mineral oil The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? "It's a sensorineural hearing loss that occurs with the aging process." The nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse should instruct the client to take which measure? Avoid air travel. The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to drain, the nurse anticipates that which measure would most likely be recommended to the client? A myringotomy The nurse is developing a plan of care for a client with a diagnosis of severe vertigo from Ménière's disease who is being admitted to the hospital. What is the priority nursing intervention in the plan of care? Safety measures The nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be a priority in the care of this client? Monitor for signs of facial nerve injury The nurse is performing an assessment on a client with a diagnosis of Ménière's disease. The nurse anticipates that the client is most likely to report which symptom during an acute attack? Tinnitus The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question? Ambulation four times daily Gastrointestinal The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? Notify the health care provider (HCP). A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. Gray-blue color at the flank, Abdominal guarding and tenderness, Left upper quadrant pain with radiation to the back The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. Fever, Complaints of indigestion, Pain in the upper right quadrant after a fatty meal A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? Increase intake of fluids, including juices. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assess 8 ment finding? Malaise A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. Administer stool softeners as prescribed., Encourage a high-fiber diet to promote bowel movements without straining., Apply cold packs to the anal-rectal area over the dressing until the packing is removed. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. Coffee, Chocolate, Peppermint, Fried chicken A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? Assessing for the return of the gag reflex The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement? "I'm glad I don't have to lie still for this procedure.” The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis? "I ate shellfish about 2 weeks ago at a local restaurant.” The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. Nuts, Liver, Lentils The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? Document the findings. Expected drainage will range from 500 to 1000 mL/day. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A rigid, boardlike abdomen The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? Irrigating the nasogastric tube The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? Limit the fluids taken with meals. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. Maintain NPO (nothing by mouth) status, Encourage coughing and deep breathing., Give hydromorphone intravenously as prescribed for pain. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? "I should increase the fiber in my diet.” The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Ask the client to extend the arms.-Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client? Pasta with sauce The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? Pain relieved by food intake A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? Lying recumbent following meals The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? Purple discoloration of the stoma A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? This is a normal, expected event. A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? Fluid and electrolyte imbalance The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? "I need to limit my intake of dietary fiber.” The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? Sweating and pallor A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? Assessment of vital signs The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? Inability to pass flatus The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? Dark red drainage A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? "I can go back to work right away.” -Rest is especially important until laboratory studies show that liver function has returned to normal. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? Leukocytosis with a shift to the left After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? Waves of loud gurgles auscultated in all 4 quadrants [Show Less]

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