NCLEX - PassPoint PN Exam, Latest

NCLEX - PassPoint PN Exam, Latest-A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is cryin ...

NCLEX - PassPoint PN Exam, Latest-A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first? Recent exposure to communicable diseases Heart rate, respiratory rate, and blood pressure Height and weight Number of immunizations received - Heart rate, respiratory rate, and blood pressure Explanation: The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later. A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? Preventing infection Providing adequate nutrition Ensuring adequate hydration Preventing contracture deformity - Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection. A client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: keep the client's knee on the affected side bent for 6 hours. remove the dressing on the puncture site after vital signs stabilize. check the client's pedal pulses frequently. apply pressure to the puncture site for 30 minutes. - check the client's pedal pulses frequently. Explanation: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short- procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so. A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands her condition and how to control it? "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "I will have to monitor my blood glucose level closely for hypoglycemia." "I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual." - "I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual." Explanation: Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. The client needs to monitor for hyperglycemia, not hypoglycemia. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low. A nurse is reinforcing education to a client diagnosed with renal calculi. Which statement made by the client suggests further instruction is indicated? "I do not need to limit my intake of tea or cola." "I should avoid foods that are high in calcium." "I should contact my health care provider if I see blood in my urine." "I should contact my health care provider if I develop flank pain again." - "I do not need to limit my intake of tea or cola." Explanation: A client with a history of kidney stones should notify the health care provider if he develops flank pain or blood in the urine. Foods high in calcium can cause calcium stones. Cola and teas can cause oxalate stones and should be avoided. The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: forcing blood into the deep venous system. elevating the extremity to prevent pooling of blood. encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. - forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this isn't how they prevent DVT. Elevating the extremity will decrease edema but won't prevent DVT. Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for: hypocortisolism. hyperglycemia. hypoglycemia. hypercalcemia. - hypocortisolism.