NCLEX Basic Care & Comfort with 100% correct answers

A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority? Assist the client with feeding. During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? keeping extraneous noise to a minimum; A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? Use a pulse oximeter to determine oxygen saturation. The nurse finds it difficult to relieve a client's pain satisfactorily. Which measure should the nurse take next when continuing efforts to promote comfort? Increase the client's confidence in the nurse. A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain? FACES Pain Rating Scale; The nurse should use the FACES pain rating scale for children age 3 or older. The visual analog and numerical scales are used preferred with adults or older children who count well. The faces, legs, activity, cry, consolability (FLACC) scale is a behavioral scale that is appropriate for very small children or nonverbal children. A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply. apple juice broth tea; A clear liquid diet includes foods that are clear (that you can see through) and are liquid at room temperature. A client is 2 days postoperative of a hip replacement. The prescriber removed the gauze dressing and gave the patient and nurse instructions to keep the site open to air. In the afternoon, the nurse observed the client rubbing an oil on the surgical site. What is likely the client's rationale regarding the application of the complementary oil? Tea tree oil has antibacterial properties; Tea tree oil is an alternative therapy that has antifungal and antibacterial uses. Clients use it to treat burns, insect bites, irritated skin, and acne. The nurse should review the prescriber's instructions with the client and also call the prescriber to report the tea tree oil application on the surgical site. A nurse is caring for a 3-year-old child following the removal of a Wilms' tumor. The parent states that the child is in pain, and requests pain medication. What is the nurse's priority in regard to this parent's request? Use the Faces Pain Scale to assess the child's degree of pain. The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? The student nurse irrigates the NG tube through the blue air vent port; The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it. When assessing a child for impetigo, the nurse expects which assessment findings? honey-colored, crusted lesions For a client with anorexia nervosa, which goal takes the highest priority? The client will establish adequate daily nutritional intake. A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position? left lateral; The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch? "I'll empty my pouch when it is about one-third full."; The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal.The client with an ileostomy must wear a pouch at all times to collect stool.The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time.A pouch can be worn for 3 to 7 days before being changed. A nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Which snacks have the greatest probability of stimulating autoimmunity? potato chips and chocolate milk shakes; A diet containing excessive fat, such as that found in potato chips and milk shakes, seems to contribute to autoimmunity — overreaction of the body against constituents of its own tissues. After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? The client reports bladder spasms and the urge to void; Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency. The nurse is preparing to initiate enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What interventions will the nurse include in the client's plan of care? Select all that apply. Change tubing and bag every 24 hours. Ensure patency of the tube prior to enteral feedings; The PEG tube should be flushed in between every feeding and access. Formula should not hang longer than 4 to 8 hours. Initial feedings should start out slowly, monitor client comfort, and change tubing/bag every 24 hours. Verification of patency prior to each feeding is essential to prevent aspiration. A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first? Inquire about the client's sleeping habits. The parent of a child with autism tells the nurse that her child is only sleeping 2 to 3 hours per night. When educating the parent about treatment for the child's sleep disturbance, the nurse should include what information? Behavioral interventions including sleep-hygiene measures are often effective in treating sleep disturbance. During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions? "I'll increase my intake of unrefined grains."; To increase peristalsis and relieve constipation, the client should increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching? "I will eat two large meals daily with frequent protein snacks."; The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate? Eat a soft, bland diet. A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number. 500 The nurse teaches the mother of a child newly diagnosed with insulin dependent diabetes about the principles of a healthy eating plan. Which statement by the mother indicates effective teaching? "Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks." Which intervention should the nurse suggest to a parent to relieve itching in a child with chicken pox? oatmeal preparation baths; Calamine lotion can be also be used if there are no open lesions. A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first? Assess the pain using a pain scale and compare to the previous assessment. Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? formula in the client's mouth during the feeding, and increased cough The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. Eat a low-purine diet. Limit alcohol intake; Gout is characterized by an abnormal metabolism of uric acid. Individuals either produce too much uric acid or their body is unable to metabolize and excrete it. Purines are metabolized into uric acid. The client who suffers from gout would be placed on a low-purine diet with foods such as peanut butter, cherries, rice, pasta, fruits, and vegetables. Fluids and sodium do not have to be limited. Alcohol intake would be limited as it is thought to trigger an exacerbation. A school-age child loses their appetite secondary to side effects of chemotherapy. What will the nurse teach the parents about nutritional choices for the child? "Let your child eat any foods that appeal to them right now." When planning pain control for a client with terminal gastric cancer, a nurse should consider that clients with terminal cancer may develop tolerance to opioids.