NURSING FUNDAMENTA NCLEX-PN Hesi Comp A
A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse?
A client with human immunodeficiency virus (HIV) infe...
a nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time when making assignments
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NURSING FUNDAMENTA NCLEX-PN Hesi Comp A
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NURSING FUNDAMENTA NCLEX-PN Hesi Comp A
A nurse who has recently completed orientation is beginning work in the
labor and delivery unit for the first time. When making assignments, which
client should the charge nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50%
effaced D
The new nurse should be assigned the least complicated client to gain
experience and confidence, as well as protect client safety. Of the clients
available for assignment, (D) is progressing well and is the least
complicated. (A, B and C) have actual or potential complications and should
be assigned to a more experienced nurse.
A client with human immunodeficiency virus (HIV) infection has white
lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin)
preparation is prescribed as a swish and swallow. Which information is most
important for the nurse to provide the client?
A.Oral hygiene should be performed before the medication. B.Antifungal
medications are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the
mouth.
D.The dietary intake of dairy and spicy foods should be
limited. A
HIV infection causes depression of cell-mediated immunity that allows an
overgrowth of Candida albicans (oral moniliasis), which appears as white,
cheesy plaque or lesions that resemble milk curds. To ensure effective
contact of the medication with the oral lesions, oral liquids should be
consumed and oral hygiene performed before swishing the liquid Mycostatin
(A). (B and C) provide the client with additional information about the
pathogenesis and treatment of opportunistic infections, but (A) allows the
client to participate in self-care of the oral infection. Dietary restriction of
spicy foods reduces discomfort associated with stomatitis, but restriction of
dairy products is not indicated (D).
A client who is admitted with emphysema is having difficulty breathing. In
which position should the nurse place the client?
A.High Fowler's position without a pillow behind the
head B.Semi-Fowler's position with a single pillow
behind the head
C.Right side-lying position with the head of the bed elevated 45
degrees D.Sitting upright and forward with both arms supported on an
over the bed table D
Adequate lung expansion is dependent on deep breaths that allow the
respiratory muscles to increase the longitudinal and anterior-posterior size of
the thoracic cage. Sitting upright and leaning forward with the arms
,supported on an over the bed table (D) allows the thoracic cage to expand in
all four directions and reduces dyspnea. A high Fowler's position does not
allow maximum expansion of the posterior lobes of the lungs (A). A semi-
Fowler's position restricts expansion of the anterior-posterior diameter of the
,thoracic cage (B). Positioning a client on the right side with the head of the
bed elevated
(C) does not facilitate lung expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of
hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily.
Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L.
What is the most likely cause of this client's potassium level?
A. The client is noncompliant with his medications.
B. The client recently consumed large quantities of pears or nuts.
C. The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium
supplement. C
The client has a normalized potassium level despite diuretic use (C). The
kidney automatically secretes 90% of potassium consumed, but in chronic
renal insufficiency (CRI), less potassium is excreted than normal. Therefore,
the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are
not likely to affect potassium levels. The normal potassium level is 3.5 to 5
mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe
that the client is noncompliant with his treatment (A). Pears and nuts do not
affect the serum potassium level (B). There is no need for a potassium
supplement (D) because the client's potassium level is within the normal
range.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for
professional liability and has the potential for a malpractice lawsuit?
A. Participating in telephone consultations with clients
B. Identifying oneself by name and title to clients in telehealth
communications C.Sending medical records to health care
providers via the Internet D.Answering a client-initiated health
question via electronic mail
C
Sending medical records over the Internet, even with the latest security
protection, creates the greatest risk for liability because of the high potential
of breaching client confidentiality and the amount of information being
transferred (C). Client confidentiality is protected by federal wiretapping laws
making telephone consultation (A) a private and protected form of
communication. By stating one's name and credentials in telehealth
communication (B), one is taking responsibility for the encounter. E-mail
initiated by the client (D) poses less risk than sending records via the
Internet.
Which pathophysiologic response supports the contraindication for opioids,
such as morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the
ICP is elevated.
, B.Higher doses of opioids are required when cerebral blood flow is reduced
by an elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with
an elevated ICP.
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