Enfermera En Estados Unidos NCLEX

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Category: NCLEX CAT

 

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1. A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this clients plan of care?

  • Ensuring a large fluid intake
  • Providing a high-calcium diet
  • Instituting seizure precautions
  • Encouraging complete bed rest

2. A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse’s best response to this question?

  • “There is no difference between readings.”
  • “These types of monitors are meant for children.”
  • “Readings are on a different scale for each monitor.”
  • “Faster readings can be obtained from a fingerstick.”

3. A clients blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse expect to identify when monitoring this client’s laboratory values?

  • Increased pH
  • Decreased PO2
  • Increased PCO2
  • Decreased HCO3

4. A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery?

  • Vasopressin (Pitressin)
  • Propylthiouracil (PTU)
  • Potassium iodide (SSKI)
  • Levothyroxine (Synthroid)

5. For which client response should the nurse monitor when assessing for complications of hyperparathyroidism?

  • Tetany
  • Seizures
  • Bone pain
  • Graves disease

6. A nurse is preparing to give a client a tepid bath and uses a bath thermometer to test the water temperature. What is the acceptable temperature range for a tepid bath?

  • 92° to 94° F
  • 95° to 97° F
  • 98° to 100° F
  • 101° to 103° F

7. A nurse is caring for a newly admitted client with a diagnosis of Graves disease. In preparing a teaching plan, the nurse anticipates which diet will be ordered for this client?

  • High-calorie diet
  • Low-sodium diet
  • High-roughage diet
  • Mechanical-soft diet

8. A health care provider orders the application of a warm soak to an IV site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?

  • Radiation
  • Insulation
  • Convection
  • Conduction

9. A nurse is planning to teach facts about hyperglycemia to a client with the diagnosis of diabetes. What information should the nurse include in the discussion about what causes diabetic acidosis?

  • Breakdown of fat stores for energy
  • Ingestion of too many highly acidic foods
  • Excessive secretion of endogenous insulin
  • Increased amounts of cholesterol in the extracellular compartment

10. A client is admitted for malignant melanoma that was discovered during a routine eye examination. For which preferred treatment does the nurse expect the client to be scheduled?

  • Radiation
  • Enucleation
  • Cryosurgery
  • Chemotherapy

11. A client with type 1 diabetes mellitus has a fingerstick glucose level of 258 mg/dL at bedtime. A prescription for sliding scale regular insulin (Novolin R) exists. What should the nurse do?

  • Call the health care provider.
  • Encourage the intake of fluids.
  • Administer the insulin as prescribed.
  • Give the client a half cup of orange juice.

12. When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe?

  • Calcium
  • Magnesium
  • Bicarbonate
  • Potassium chloride

13. A nurse identifies that the client is experiencing a hypoglycemic reaction. Which nursing intervention should the nurse implement to relieve the symptoms associated with this reaction?

  • Giving 4 oz of fruit juice
  • Administering 5% dextrose solution IV
  • Withholding a subsequent dose of insulin
  • Providing a snack of cheese and dry crackers

14. Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis?

  • Monitoring for signs of hypoglycemia as a result of treatment
  • Withholding glucose in any form until the situation is corrected
  • Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally
  • Regulating insulin dosage according to the amount of ketones found in the client’s urine

15. A client has a glycosylated hemoglobin measurement of 6%. What should the nurse conclude about this client when planning a teaching plan based on the results of this laboratory test?

  • Is experiencing a rebound hyperglycemia
  • Needs the insulin changed to a different type
  • Has followed the treatment plan as prescribed
  • Requires further teaching regarding nutritional guidelines

16. A nurse in the postanesthesia care unit is caring for a client who just had a thyroidectomy. For which client response is it most important for the nurse to monitor?

  • Urinary retention
  • Signs of restlessness
  • Decreased blood pressure
  • Signs of respiratory obstruction

17. A client with hyperthyroidism asks the nurse about the tests that will be ordered. Which diagnostic tests should the nurse include in a discussion with this client?

  • T4 and x-ray films
  • TSH assay and T3
  • Thyroglobulin level and Po2
  • Protein-bound iodine and SMA

18. A nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe periph­ eral edema. For which clinical indicators associated with unresolved severe peripheral edema should the nurse assess the client?

  • Proteinemia
  • Contractures
  • Tissue ischemia
  • Thrombus formation

19. On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first?

  • Reorder the full-fluid diet.
  • Notify the health care provider.
  • Administer analgesics as prescribed before meals.
  • Provide saline gargles to moisten the mucous membranes.

20. The nurse identifies that the dietary teaching provided for a client with diabetes is understood when the client states, “My diet:

  • should be rigidly controlled to avoid emergencies.”
  • can be planned around a wide variety of commonly used foods.”
  • is based on nutritional requirements that are the same for all people.”
  • must not include eating any combination dishes and processed foods.”

21. A nurse is caring for a client admitted for removal of basal cell carcinoma and reconstruction of the nose. About which contributing factor should the nurse question the client when collecting a health history?

  • Dietary patterns
  • Familial tendencies
  • Amount of tobacco use
  • Ultraviolet radiation exposure

22. A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the clients condition after this therapy should the nurse consider when providing care?

  • Not radioactive and can be handled as any other individual
  • Highly radioactive and should be isolated as much as possible
  • Mildly radioactive but should be treated with routine safety precautions
  • Not radioactive but may still transmit some dangerous radiations and must be treated with precautions

23. A nurse is caring for a client who is experiencing an underproduction of thyroxine. Which client response is associated with an underproduction of thyroxine (T4)?

  • Myxedema
  • Acromegaly
  • Graves disease
  • Cushing disease

24. A nurse is transferring a client with a diagnosis of pheochromocytoma from a bed to a chair. What is the most important nursing intervention associated with this procedure for this client?

  • Supporting the client on the weak side
  • Ensuring that the chair is close to the clients bed
  • Placing sturdy shoes with rubber soles on the clients feet
  • Having the client sit on the side of the bed for a few minutes before the transfer

25. A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experi-encing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing?

  • Somogyi effect
  • Dawn phenomenon
  • Diabetic ketoacidosis
  • Hyperosmolar nonketotic syndrome

26. A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, “I will:

  • cut my toenails before bathing.”
  • soak my feet daily for one hour.”
  • examine my feet using a mirror at least once a week.”
  • break in my new shoes over the course of several weeks.”

27. A nurse administers the prescribed regular insulin (Novolin R) to a client in diabetic ketoacidosis. In addition, the nurse anticipates that the IV solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being:

  • rapidly lost from the body by copious diaphoresis present during coma.
  • carried with glucose to the kidneys to be excreted in the urine in increased amounts.
  • quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose.
  • moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose.

28. A nurse is caring for a client with type 1 diabetes, and the health care provider prescribes one tube of glucose gel. What is the primary reason for the administration of glucose gel to this client?

  • Diabetic acidosis
  • Hyperinsulin secretion
  • Insulin-induced hypoglycemia
  • Idiosyncratic reactions to insulin

29. A 24-hour urine test is ordered for a client who has a tenta­ tive diagnosis of pheochromocytoma. What should the nurse do?

  • Start the time of the test after discarding the first voiding.
  • Discard the last voiding in the 24-hour time period for the test.
  • Insert a urinary retention catheter to promote the collec­ tion of urine.
  • Strain the urine following each voiding before adding the urine to the container.

30. A nurse working in the diabetes clinic is evaluating a client’s success with managing the medical regimen. Which is the best indication that a client with type 1 diabetes is successfully managing the disease?

  • Reduction in excess body weight
  • Stabilization of the serum glucose
  • Demonstrated knowledge of the disease
  • Adherence to the prescription for insulin

31. A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary?

  • “I need to rub my forearm vigorously until warm before testing at this site.”
  • “The fingertip is preferred for glucose monitoring if hyperglycemia is suspected.”
  • “Alternate site testing is unsafe if I am experiencing a rapid change in glucose levels.”
  • “I have to make sure that my current glucose monitor can be used at an alternative site.”

32. A client with psoriasis asks the nurse what can help this condition. Which should the nurse include in a teaching plan for this client?

  • Avoiding exposure to the sun
  • Topical application of steroids
  • Potassium permanganate baths
  • Debridement of necrotic plaques

33. A nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. Which type of graft is going to be applied by the health care provider?

  • Isograft
  • Allograft
  • Homograft
  • Heterograft

34. A nurse is evaluating a clients fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client’s fluid loss?

  • BUN
  • Blood pH
  • Hematocrit
  • Sedimentation rate

35. A nurse is caring for a client with scabies. Which informa­tion about scabies should the nurse consider when planning care for this client?

  • Highly contagious
  • Caused by a fungus
  • Chronic with exacerbations
  • Associated with other allergies

36. Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission?

  • Severe pain
  • Maintenance of sterility
  • Alteration in body image
  • Frequent dressing changes

37. A nurse plans an evening snack of milk, crackers, and cheese for a client who is receiving NPH insulin (Novolin N). What does this snack provide?

  • Encouragement to stay on the diet
  • Added calories to promote weight gain
  • Nourishment to counteract late insulin activity
  • High-carbohydrate nourishment for immediate use

38. A nurse is caring for a client newly diagnosed with type 1 diabetes. When the health care provider tries to regulate this client’s insulin regimen, the client experiences episodes of hypoglycemia and hyperglycemia and 15 g of a simple sugar is prescribed. What is the reason this is administered when a client experiences hypoglycemia?

  • Inhibits glycogenesis
  • Stimulates release of insulin
  • Increases blood glucose levels
  • Provides more storage of glucose

39. A nurse is assessing a client for possible laryngeal nerve injury following a thyroidectomy. Which action should the nurse implement on an hourly basis?

  • Ask the client to speak.
  • Instruct the client to swallow.
  • Have the client hum a familiar tune.
  • Swab the client’s throat to test the gag reflex.

40. Propylthiouracil (PTU) is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, “Why do I have to take this medication if I am going to get the atomic cocktail?” The nurse explains that the medication is being prescribed because it decreases the:

  • vascularity of the thyroid gland.
  • production of thyroid hormones.
  • need for thyroid iodine supplements.
  • amount of already formed thyroid hormones.

41. What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy?

  • Inspect the incision.
  • Instruct the client not to speak.
  • Place a tracheostomy set at the bedside.
  • Place in the supine position for twenty-four hours.

42. A urine specimen is needed to test for the presence of ketones in a client who is diabetic. What should the nurse do when collecting this specimen from a urinary retention catheter?

  • Disconnect the catheter and drain the urine into a clean container.
  • Clean the drainage valve and remove the urine from the catheter bag.
  • Wipe the catheter with alcohol and drain the urine into a sterile test tube.
  • Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine.

43. A client newly diagnosed with scleroderma states, “Where did I get this from?” The nurse’s best response is “Although no cause has been determined for scleroderma, it is thought to be the result of:

  • autoimmunity.”
  • ocular motility.”
  • increased amino acid metabolism.”
  • defective sebaceous gland formation.”

44. A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse’s primary responsibility 2 days after surgery when preparing the client to eat dinner?

  • Checking the client’s serum glucose level
  • Assisting the client out of bed into a chair
  • Placing the client in the high-Fowler position
  • Ensuring the client’s residual limb is elevated

45. A nurse is caring for a client with diabetes who is scheduled for a radiographic study requiring contrast. Which should the nurse expect the health care provider to prescribe?

  • Acetylcysteine (Acetadote) before the test
  • Renal-friendly contrast medium for the test
  • Forced diuresis with mannitol (Osmitrol) after the test
  • Hydration with dextrose and water throughout the test

46. For which clinical manifestation should the nurse assess a client with metastatic melanoma?

  • Oily skin
  • Nikolsky sign
  • Lymphadenopathy
  • Erythema of the palms

47. A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery?

  • Tetany
  • Myxedema
  • Hypovolemic shock
  • Adrenocortical stimulation

48. A nurse is monitoring a client’s fasting plasma glucose (FPG) level. At which FPG level should the nurse identify that the client has prediabetes?

  • 70 mg/dL
  • 100 mg/dL
  • 130 mg/dL
  • 160 mg/dL

49. A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a clients burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

  • Equal
  • Unrelated
  • Inversely related
  • Directly proportional

50. A nurse is caring for a client with the diagnosis of pemphigus vulgaris. Which expected response does the nurse need to address in the client’s plan of care?

  • Paralysis
  • Infertility
  • Skin lesions
  • Impaired digestion

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