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KAPLAN NCLEX PREDICTOR COMPLETE SOLUTION PACKAGE for 2022/2023
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Kaplan Predictor c Exam latest updated
Kaplan Predictor c Exam latest updated Which of these actions best demonstrates cultural sensitivity by a nurse? - ANSWER The nurse asks clients about... [Show More] their beliefs and practices toward pregnancy. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? - ANSWER Tachycardia. When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: - ANSWER the urinary meatus. Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy. - ANSWER Sharp unilateral abdominal pain. A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? - ANSWER Encourage the client to verbalize feelings. Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode? - ANSWER Providing pain relief. Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today? - ANSWER "Call the clinic if you experience any abdominal cramps." A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? - ANSWER Check the residual volume. An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? - ANSWER Beefburger with cheese. A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis? - ANSWER Elevated serum amylase level. Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately? - ANSWER Vomiting and a pulse rate of 106/minute. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? - ANSWER Tachycardia. Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? - ANSWER The student sits quietly next to the client. Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? - ANSWER Measure the client's blood sugar level. Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye? - ANSWER "Take the prescribed stool softener to avoid increasing intraocular pressure." An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? - ANSWER Increasing the time interval between medication doses. A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? - ANSWER Allowing the client to eat food from sealed containers. Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? - ANSWER Apply sequential compression devices. When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: - ANSWER 25 to 35 pounds. Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? - ANSWER "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort." A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin Blood sugar 181-200 mg: Give 4 units regular insulin Blood sugar 201-220 mg: Give 6 units of regular insulin Blood sugar above 220 mg: Call MD At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer? - ANSWER 0.04 Which of these nursing diagnosis is the priority for a client who is one-hour postoperative after extensive abdominal surgery? - ANSWER Risk for ineffective airway clearance. A nurse should recognize that which of these occupations increases a person's risk of developing hepatitis B? - ANSWER Hemodialysis nurse. Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck? - ANSWER Respiratory status. A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions? - ANSWER Side-lying. Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus? - ANSWER "Apply lotion to your feet each day." A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? - ANSWER Assess the client. An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? - ANSWER Stop the transfusion. When caring for a client who has hepatitis B, a nurse should wear: - ANSWER gloves when removing the intravenous cannula. Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? - ANSWER Clear lung sounds on auscultation. A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? - ANSWER "Are you using a straw to administer the medicine?" Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? - ANSWER Decreased urine output. Which of these instructions should be included in the teaching plan for the parents of a 10-month-old infant who is admitted to the hospital for failure to thrive? - ANSWER Encourage the mother to feed the infant slowly in a quiet environment. When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn's jaundice? - ANSWER Liver immaturity. Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet? - ANSWER Ketchup. Which of these statements, if made by a client who had a total hip replacement, would indicate a correct understanding of the postoperative instructions? - ANSWER "I will use a raised toilet seat in the bathroom." Which of these measures should a nurse include when planning care for an 88-year-old client who is admitted to the hospital with pneumonia? - ANSWER Allowing the client to perform self-care as tolerated. A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished business as soon as possible." Which of these responses is appropriate? - ANSWER "It sounds like you are concerned with your diagnosis." Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning? - ANSWER Keeping an accurate record of intake and output. A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? - ANSWER Respiration, 30/minute and deep. When determining the duration of a uterine contraction, a nurse should measure the contraction from the: - ANSWER beginning of one contraction to the end of that contraction. A nurse should recognize which of these signs is a probably sign of pregnancy? - ANSWER Positive pregnancy test. All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? - ANSWER An 84-year-old client who has been NPO for four days. A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has: - ANSWER been in relatively good diabetic control. A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include? - ANSWER Wearing a gown, mask, and gloves when providing care to the client. A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer? - ANSWER 2.0 A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? - ANSWER Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? - ANSWER The client is showing signs of pressure; press on the skin and observe for a return of color. A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: - ANSWER cover the newborn's closed eyes with patches. Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? - ANSWER Diaphoresis. A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication? - ANSWER BP 92/60 mm Hg, pulse rate 118/minute. A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include: - ANSWER flushed skin and thirst. Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism? - ANSWER Partial thromboplastin time. Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding? - ANSWER Aspirate 10 mL contents and measure the pH. A client has shortness of breath when lying down and usually assumes an upright or sitting position in order to breathe more comfortably. A nurse should document this observation as: - ANSWER orthopnea. Which of these instructions should a nurse give to a client when collecting a sputum specimen? - ANSWER "Take a deep breath, then cough and spit into this container." A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client? - ANSWER Risk for deficient fluid volume. Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a gluten-free diet? - ANSWER Broiled steak, baked potato, and spinach. Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's feelings and concerns? - ANSWER "Everything will be okay." A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job." Which of these responses, if made by the nurse, will create a communication barrier? - ANSWER "You need to relax, and everything will be fine." A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make? - ANSWER Measure the client's body temperature. Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury? - ANSWER Administering the missing factor VIII to the child. Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? - ANSWER Preventing aspiration. A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse take? - ANSWER This may be an early sign of heart failure; notify the physician. Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse recognize as indicative of a need for additional instructions? - ANSWER Egg salad sandwich with mayonnaise, pickles, and seltzer water. Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing diagnosis of knowledge deficit? - ANSWER "I will need to add more salt to my diet because this medication will increase its excretion." Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates improvement? - ANSWER "I can now walk one more block than I could last month." An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions should a nurse plan? - ANSWER Consistently assign the care of the infant to the same staff. Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions? - ANSWER Initially demonstrate and explain the procedure to the client. Which of these laboratory test results is more important for a nurse to assess for a client who reports chest pain? - ANSWER Troponin level. A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure: - ANSWER glucose and protein. Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia? - ANSWER Suspiciousness. Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? - ANSWER Encouraging the parents to take the opportunity to say goodbye. Which of these assessments is the priority for a client who is admitted with recurrent depression? - ANSWER Presence of a suicide plan. Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? - ANSWER Increased urine output. Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate? - ANSWER The UAP is assigned to measure a client's intake and output. A client who has a history of asthma develops an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack? - ANSWER "Have you eaten any new foods recently?" [Show Less]
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KAPLAN NCLEX PREDICTOR VERSION 2- 150 VERIFIED Q & A for 2022-2023
KAPLAN NCLEX PREDICTOR VERSION 2- 150 VERIFIED Q & A for 2022-2023 Predictor Version 2 1. The nurse shows a teenager how to use a metered dose inhaler o... [Show More] f ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who paces continuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect. 4. Observe the clients throat while she swallows several times after putting the medication in her mouth. 10. The nurse assesses a patient 72 hours after a total joint replacement of the right hip. Which finding requires an intervention by the nurse? 1. There is a pillow between the patients legs 2. The patient’s legs are internally rotated 3. The patients hip joint is flexed at a 70 degree angle when the patient sits in the chair 4. The patient has not requested pain medication for 12 hours. 11. A client newly diagnosed with Meniere’s disease plans a trip to an amusement park with the family. The client asks the clinic nurse which of the following rides is best. The nurse should suggest which of the following rides? 1. Roller coaster 2. Merry go round 3. Ferris wheel 4. Train 12. A client is discharged from the hospital after coronary bypass (CABG) surgery 3 days ago. During discharge teaching, the client asks the nurse “When can I resume sexual intercourse with my wife?” it is best for the nurse to make which of the following statements? 1. “You can resume sexual activity when you feel strong enough” 2. “You can resume sexual activity when you are able to walk one block without chest pain or discomfort” 3. “You may have difficulty maintaining an erection because of your recent surgery” 4. “You should abstain from sexual activity because it may be detrimental to your recovery” (one block or two flights of stairs without chest pain) 13. A woman complains to the nurse about the care provided to her husband by the nursing staff the previous night. Initially, the nurse should take which of the following actions? 1. Ask the wife to voice her expectations about a solution to the problem 2. Gain consensus with the woman on the specific steps that will be taken care for her husband 3. Explain to the wife that the problems she identified will be fixed 4. Notify the wife that everything possible is being done for her husband 14. A patient is restrained bodily by the nursing team. The hands of the nurse assigned to hold down the patients leg should be placed in which of the following positions? 1. One hand on the patients knee and the other hand on the patients ankle 2. One hand directly above the patient’s knee and the other hand directly above the patient’s ankle 3. Both hands side by side on the patients thighs 4. One hand at the patients groin and the other hand at the patients mid-calf area 15. The nurse in the community mental health center works with a client who is diagnosed with depression. Cognitive therapy is initiated. The nurse should take which of the following actions? 1. Assist the client to review past intellectual achievements 2. Help the client develop more positive thoughts 3. Help the client to identify the source of his depression 4. Change the client’s values and beliefs. Cognitive Therapy; determined that how individuals feel and behave is determined by how they think about the world and their place in it. 16. The nurse plans to perform a physical assessment of a young adult who has been deaf since birth. Although the client indicates using sign language, no interpreter is available. The nurse should take which action? 1. Face the client and speak slowly using low-pitched voice 2. Write out each question, and ask the client to write out each answer 3. Sit on the clients right side and use gestures and nonverbal clues 4. Show the client pictures of the parts of the body that will be examined 17. A patient received morphine 4 mg IV 2 hours ago for the complaints of postoperative pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The patient has bathroom privileges. The nurse should take which of the following actions? 1. Obtain a bedside commode for the patient to use 2. Provide a warmed fracture bedpan for the patient to use 3. Tell the patient to breathe deeply as he walks to the bathroom 4. Ask the patient sit on the side of the bed before proceeding to the bathroom Answer#4 18. The nurse cares for a patient on the psychiatric unit with a history of drug use and poor impulse control. After the patient’s mother visits, the patient begins pacing rapidly, with arms swinging, and kicking at chair legs. The nurse should approach the patient and take which of the following actions? 1. Sit in a chair several feet away from the patient and lean forward with hands clasped together 2. Stand facing the patient with legs apart, knees locked, and weight on back leg 3. Sit in a chair next to the patient and lean back with arms folded 4. Stand facing the patient, legs together, knees locked, with weight on both legs Answer#2 19. The nurse observes the nursing assistant giving morning care to an elderly client who has an area of warm, reddened skin on the sacrum that does not blanch with pressure. Which action by the nursing assistant requires an intervention by the nurse? 1. The aide cleanses and then applies A and D ointment to the reddened area 2. The aide firmly massages the reddened area in a circular motion 3. The aide placed a piece of sheepskin under the patients sacrum 4. The aide positions the patient on the left side with head of the bed flat Answer#2 (Stage Ipressure ulcer, do not massage can damage capillary beds and cause tissue necrosis) 20. The school nurse identifies several children who have food allergies. Which sequence should the nurse teach the staff to follow if an allergic reaction is observed in a child? 1. Call 911, call the physician, administer EpiPen, call the parents 2. Administer the EpiPen, call 911, call the physician, call the parents 3. Call the physician, administer the EpiPen, call 911, call the parents 4. Call the parents, administer the EpiPen, call the physician Answer#2 21. A client comes to the ER complaining of shortness of breath, fatigue, insomnia, and weight loss. The client states that the client’s company forced the client into early retirement. The client says that the client has been sick ever since the client stopped working. The nurse should take which of the following actions first? 1. Encourage the patient to find outlets for his job skills in a consultative or volunteer basis in the community 2. Help the client see a connection between his symptoms and emotions, while investigating each symptom 3. Tell the client that anger is an unacceptable reason to something being taken away 4. Explain to the client what retirement should be like, and contrast this with what he has experienced 22. The nurse teaches the woman diagnosed with type 1 diabetes who is pregnant for the first time. The nurse teaches the client that as the pregnancy advances, the client may require which implementation? 1. Decreased amounts of insulin 2. Increased amounts of insulin 3. Decreased amounts of carbohydrates in her diet 4. Increased amounts of protein in her diet Answer#2 23. The nurse cares for a patient after a colon resection. The patient has a Salem sump tube connected to intermittent suction. The patient asks the nurse, “When will I be able to eat?” Which is the BEST response by the nurse? 1. “You will be given a high-calorie, high-fiber diet in a few days” 2. “You will be started on clear liquids when we hear your stomach make noises” 3.”You can eat food when the NG tube is removed in about 5 to 6 days” 4. A soft diet will be given to you after you have your first bowel movement” 24. The nurse supervises care provided for a client immediately after cardioversion. Which observation, if made by the nurse, indicates the need for an intervention? 1. A cold cloth has been applied to the paddle sites on the patient’s chest 2. The patient’s dentures remain in a cup at the bedside 3. There is an NPO sign above the patients bed 4. The oxygen the patient was receiving before the procedure remains disconnected 25. The nurse cares for a client diagnosed with bursitis of the right shoulder. The nurse expects the client to experience which of the following? 1. Pain and numbness in the first two fingers and thumb of her right hand 2. Spasms of the right hand when a blood pressure cuff is initiated and left in place for 2 minutes 3. A constant dull ache originating in the neck and radiating down the right arm 4. Pain with extension, flexion, and internal rotation of the right arm 26. The nurse supervises care provided by the nursing assistive personnel (NAP) to the older client in the convalescent phase after a stroke. The nurse should intervene if which action is observed? 1. The client is supine with a pillow under the head 2. The client is positioned laterally on the left side with the head of the bed flat 3. The client sits with the head of the bed elevated and the knee gatch up 4. The client is positioned laterally on the right side with the head of the bed flat (Brain attack or CVA; keep head unaffected side, no neck flexion or extension, head of bed flat) 27. The nurse cares for a client who is receiving amitriptyline (Elavil) 25 mg q A.M. and 100 mg at HS. The nurse understands that the medication schedule will accomplish which of the following? 1. Make therapeutic use of an expected side effect of the medication 2. Decrease interference between digestion of food and absorption of medication 3. Utilize the increased permeability of the blood-brain barrier that occurs during sleep 4. Reduce the side effects experienced by the client (Antidepressant, tryciclic; it has a sedative effect, administer larger dose at night it causes increased sedation) 28. An older patient falls on the floor of the psychiatric unit. To determine the cause of the fall, it is MOST important for the nurse to do which of the following? 1. Check the patients eyeglasses 2. Examine the condition of the patients shoes 3. Monitor the patients’ blood pressure 4. Evaluate the floor where the patient fell 29. The nurse instructs a prenatal class for first-time mothers. A group of mothers state they are afraid because they have heard that babies often die in their sleep before their first birthday. The mothers ask what they can do to prevent this. It is BEST for the nurse to make which of the following responses? 1. it’s important for you to focus on your pregnancy and upcoming labor and not to focus onnegative things that may happen in the future 2. This does not happen very often. With good nutrition and loving care your babies should thrive and develop normally 3. Unfortunately, the cause of this condition is not definitely known, so there is little you cando to prevent this from happening 4. It’s best to position the baby on its back or side in bed. There seems to be an increase in this condition when babies are put to sleep on their stomach Answer#4 30. A client attends a support group for incest survivors at the community mental health center. The client tells the nurse, “I don’t get it. People keep telling me I talk just like my father. He’s the last person I’d want to act like!” which response by the nurse is BEST? 1. Genetically, you are like your father 2. You need to be more open-minded. I’m sure your father had some good qualities 3. Don’t worry about what everyone else is saying 4. Sometimes people unconsciously take on the characteristics of people who exert power over them To exert is to apply or use. Waleska=mami 31. The family of a patient admitted to the psychiatric unit 3 days ago arrives for a visit carrying two suitcases. The nurse informs the family that before they can proceed into the unit, the suitcases need to be searched. The family asks why this needs to be done. Which is the BEST response by the nurse? 1. “We know what is best for our patients” 2. “We have to make sure you’re not bringing contraband” 3. “Were just following the rules established by administration” 4. “Things that you may not think of as being harmful may be used for harm by the patient 32. The nurse asks the nursing assistant to obtain morning vital signs on several patients. It is best for the nurse to make which of the following statements? 1. “Go check the vital signs for the patient in rooms 321 and 322. Record your findings on this sheet and then return it to me” 2. “Today you’ll check patient’s vitals. Please start with rooms 321 and 322. Be sure to write them down” 3. “Since you have been taught to check vital signs for patients, you can take them on patients in rooms 321 and 322. Let me know your findings” 4. “The patients in room 321 and 322 need to have their morning vital signs taken. This allows us to compare the results to what the night nurse documented.” 33. The nurse reviews basic communication skills with a new group of nursing assistants. It is BEST for the nurse to make which of the following statements? 1. “Understanding nonverbal behavior assures success in interpersonal relationships 2. “Nonverbal behavior is best considered in combination with verbal communication” 3. “There is no specific meaning for each type of nonverbal behavior” 4. “Altering nonverbal behavior is a form of manipulation” 34. The nurse cares for a woman at 7 months gestation diagnosed with preeclampsia. The client comes to the outpatient clinic for her weekly checkup. The nurse is MOST concerned if which of the following is observed? 1. The clients temperature is 98.2 F (36.7 C) 2. The client has 2+ pitting edema of her feet 3. The client gained 1 pound since the last visit 4. The client’s skin is dry [Show Less]
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KAPLAN NCLEX EXAM 7 (270 VERIFIED QUESTIONS AND ANSWERS)
KAPLAN NCLEX EXAM 7 (270 VERIFIED QUESTIONS AND ANSWERS) 1. The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital.... [Show More] Which of the following plans would be a priority to meet the needs of this father? 1. Encourage the father to call his wife after work. 2. Instruct the father about visiting policy and suggest AM visitation. 3. Adjust visiting hours to meet the new parents’ needs. 4. Present a change of visiting hours to the appropriate hospital committee. Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? (1) inflexible (2) inflexible (3) correct–role of nurse is to be a family and client advocate; this provides individualized care not a priority, although it may be an appropriate long-range goal (4) not a priority, although it may be an appropriate long-range goal 2. The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST? 1. “After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.” 2. “I saw my coworker downtown after work. S/he was acting really strange, like s/he didn’t even recognize me.” 3. “I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.” 4. “My coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.” Strategy: All answers are assessment. Determine how each relates to the situation. (1) correct—report objective information that can be verified; clues to possible substance abuse by staff include memory lapses, frequent absences from the floor, increased number of clients reporting unrelieved pain or insomnia (2) subjective observation (3) subjective observation (4) “hanging around with drug dealers” is subjective 3. A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders? 1. Theophylline (Somophyllin) 0.7 mg/kg/hr IV. 2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd. 3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid. 4. Propranolol hydrochloride (Inderal) 40 mg PO bid. Strategy: You are looking for an incorrect medication. Think about the action of each drug. (1) drug of choice for acute asthma (2) broad spectrum antibiotic, not contraindicated (3) blocks parasympathetic stimulation and decreases mucus; used with asthma (4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction 4. A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, “I guess we just don’t get along.” Which of the following responses by the nurse is MOST appropriate? 1. “Your wife seems to be upset by the situation.” 2. “Perhaps you should both go home now.” 3. “Try to think about what precipitated her crying.” 4. “The situation is difficult for both of you.” Strategy: Remember therapeutic communication. (1) nontherapeutic; emphasis is placed on wife, not the situation (2) nontherapeutic; closes off communication (3) nontherapeutic; appears to blame the husband for precipitating the wife’s behavior, would cause him to react defensively (4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife 5. A client on chemotherapy has a WBC count of 1,200/mm3. Which of the following nursing actions should the nurse take FIRST? 1. Check temperature q4h. 2. Monitor urine output. 3. Assess for bleeding gums. 4. Obtain an order for blood cultures. Strategy: Determine how each assessment relates to a low white count. (1) correct—important to monitor for infection which would be evidenced by an elevated temperature in a client with a low WBC (2) important because of problems of increased uric acid excretion from chemotherapeutic drugs but should not be done first (3) would be associated with a low platelet count (4) would be done if the temperature were elevated to determine the type of organism involved 6. A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a “dry labor.” Which of the following responses by the nurse would be MOST appropriate? 1. “The amniotic fluid provides only minimal lubrication for the labor process.” 2. “The amniotic sac may impede the progress of labor and is often ruptured artificially.” 3. “Labor is only slightly more difficult with early rupture of the amniotic sac.” 4. “Because there is limited amniotic fluid, additional fluids will be supplied.” Strategy: “MOST” indicates there may be more than one answer that you like. (1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal development, facilitates symmetrical growth, maintains constant body temperature, is a source of oral fluids, and collects wastes (2) correct— sometimes done to assist or induce labor (3) does not make labor more difficult (4) no additional fluids will be supplied 7. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed? 1. Redness or inflammation of the tissue. 2. Mottling or graying of the tissue. 3. The client states that she feels a burning and tingling sensation in the area. 4. The client state that she feels a numbness and a cold sensation in the area. Strategy: “MOST concerned” indicates a complication. (1) indicates inflammation (2) correct—site should be observed every five minutes for signs of tissue intolerance, including blanching, mottling, or graying (3) usually indicates ischemia or sensorineural impairment (4) expected outcome of numbness, which would lead to decreased pain perception 8. The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders? 1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute. 2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained bradycardia below 30. Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct—in complete heart block, the AV node blocks all impulses from the SA node so the atria and ventricles beat independently; because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response; cardiac depressants are contraindicated in the presence of complete heart block (2) appropriate treatment (3) appropriate treatment (4) appropriate treatment 9. The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift? 1. Resting after receiving IM pain medication. 2. No bowel sounds present. 3. IV infusing at 100 cc/h. 4. Breath sounds decreased in both lower lobes. Strategy: Priority question. Remember Maslow and the ABCs. (1) psychosocial; not a priority (2) physical; expected finding after surgery due to decrease in peristalsis from anesthetic agents (3) physical; not a priority (4) correct—physical; incision for a cholecystectomy is high on the abdominal wall, which inhibits ventilatory movement; decreased breath sounds might indicate a complication of pneumonia 10. The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to 1. increase the amount of calcium in her daily diet. 2. increase the amount of vitamin D in her daily diet. 3. increase the amount of time she is exposed to sunlight. 4. increase her activities that involve weight-bearing. Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) diet should have adequate calcium, should increase intake in middle age to protect against skeletal demineralization; not most important (2) adequate serum levels of vitamin D needed for calcium to be absorbed from GI tract, should increase intake in middle age to protect against skeletal demineralization; not most important (3) vitamin D is synthesized in the skin with exposure to sunshine; not most important for this patient (4) correct—weight bearing and exercise primary ways to develop high-density bones, decrease bone reabsorption and stimulate bone formation; would also help maintain mobility with left- sided weakness 11. The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed? 1. “I have been very careful to wash my hands after I go to the bathroom.” 2. “I have had to take Tylenol several times this week for this sinus infection I have.” 3. “I have been very careful not to handle my child’s toys or eating utensils.” 4. “My husband has been preparing all of the meals since I’ve been sick.” Strategy: “Further teaching is needed” indicates you are looking for an incorrect response. (1) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand- washing techniques and avoiding contact with items that will be placed in others’ mouths (2) correct— client should be cautioned about taking any drugs not approved by the health care provider; may become dangerous because of the liver’s inability to detoxify and excrete them (3) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others’ mouths (4) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others’ mouths 12. The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals? 1. Tuna salad sandwich and orange slices. 2. Bologna sandwich and french fries 3. Milkshake and banana. 4. Fried chicken and tossed salad. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired (1) correct—manic clients need nutritious finger foods; foods contain protein, carbohydrates, vitamin C, and fiber (2) finger foods, but little nutritive value (3) finger foods, not as balanced (4) too difficult to eat in manic phase 13. Which of the following actions should the nurse instruct the client to complete FIRST to establish a normal urinary pattern? 1. Urinate every two hours. 2. Record each time you urinate. 3. Keep a record of your daily fluid intake. 4. Stay near a bathroom. Strategy: Answers are all implementations. Determine the outcome of each answer. Is it desired? (1) client should start voiding every 2 h and gradually progress to 3–4 h (2) second thing to do (3) correct— client needs to know how much and when he ingests fluid (4) appropriate, but not the first thing to do 14. The nurse is receiving reports about four pregnant women in active labor who have been admitted to the labor and delivery unit. Which of the following women should the nurse see FIRST? 1. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of 2 cm, fetus in transverse lie with baseline FHT of 155 bpm. 2. A 32-year-old multipara at term, cervical dilatation of 8 cm, fetus in a vertex presentation with the presenting part at +2 station. 3. A 22-year-old nullipara at term, cervical dilatation of 10 cm, 100% effaced, fetus presenting as left occiput posterior with short-term variability of the FHT at 3–5 beats. 4. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical dilatation of 3 cm, and fetus in a frank breech presentation with the presenting part at 0 station. Strategy: Determine who is the least stable client. (1) delivery is not imminent (2) correct—transition phase of labor and delivery quick for many multipara woman (3) nullipara women usually have a longer second stage than multipara women (4) labor has not progressed very far 15. The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is MOST important for the nurse to take which of the following actions? 1. Remove the appliance regularly and clean the skin with antiseptic solution. 2. Apply a close-fitting drainage bag to the stoma. 3. Massage the skin around the stoma with an emollient. 4. Expose the area around the stoma to air twice a day. Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? (1) soap and water should be used to clean the skin, not an antiseptic solution (2) correct—primary preventative measure to prevent urine from contacting the skin (3) would hinder the application of the bag for urine collection (4) unnecessary; would not help prevent skin breakdown 16. Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest? 1. Soak the intubation equipment in concentrated Betadine solution. 2. Place the intubation blade in a bag and arrange for gas sterilization. 3. Soak the intubation blade in Cidex solution. 4. Wash the equipment with soap and water and allow to air-dry. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate action (2) correct—sterilization of equipment after exposure to body fluids of a client is protocol (3) inappropriate action (4) inappropriate action 17. The nurse is caring for a toddler in traction, and the toddler is receiving chloral hydrate (Noctec). The toddler becomes irritable and extremely restless. Which nursing action is MOST appropriate? 1. Give the next dose of chloral hydrate early. 2. Contact the physician to obtain new orders. 3. Instruct the toddler’s mother to read to him. 4. Take the toddler out of traction for 30 minutes. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) would probably increase the restlessness and worsen the condition by giving the toddler more medication (2) correct—chloral hydrate, a sedative, can have the opposite effect on a toddler, causing excitability (3) restless due to chloral hydrate (4) toddler should remain in traction 18. The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective? 1. Cheeseburger with tomato and onion. 2. Spaghetti with meat sauce and green beans. 3. Tuna fish sandwich with orange juice. 4. Grilled cheese sandwich and chocolate pudding. Strategy: Type of diet needed by the client is unstated. Determine what type of diet is required and select the appropriate menu. (1) should have high-fiber, low-fat diet; this diet is high in fat (2) correct—high-fiber diet is an important part of bowel program; fiber helps prevent the complication of constipation; includes whole-grain foods, bran, fresh and dried fruits; increased fiber will facilitate defecation, especially with reduction in fat intake (3) should increase intake of fiber foods and decrease intake of fat (4) should have high-fiber, low-fat diet; this is a high-fat diet 19. The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant’s mother made which of the following statements? 1. “My daughter has almost doubled her birth weight.” 2. “When I walk in the room my child smiles at me.” 3. ”When she is around her grandpa, my child cries.” 4. “My daughter can’t quite say Mama yet.” Strategy: “MOST concerned” indicates you are looking for something wrong. (1) correct—weight should double by 5 months (2) begins to recognize parents at 6 months (3) begins to fear strangers at 6 months, increases until 9 months (4) begins to say “dada” and “mama” with meaning at 10 months 20. A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, “My parents are mean and don’t really care about me.” Which of the following responses by the nurse is BEST? 1. “You feel your parents don’t care about you?” 2. “Your parents brought you to the clinic, didn’t they?” 3. “I am sure that your parents have your best interests at heart.” 4. “Did you have a disagreement with your parents?” Strategy: Remember the principles of therapeutic communication. (1) correct—uses therapeutic technique of reflecting; validates feelings without placing value judgment or giving approval or disapproval (2) negates client’s feelings, blocks communication (3) negates client’s feelings, blocks communication (4) yes/no question 21. A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to 1. suction the patient frequently. 2. provide an air mattress. 3. turn the patient every two hours. 4. give the patient frequent baths. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) decreases oxygen levels, is uncomfortable and unnecessary (2) equipment is not most important (3) correct—prevents complications such as skin breakdown (4) will dry out her skin and cause chilling 22. One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to 1. notify the physician. 2. call the lab for a blood glucose level. 3. offer the client milk and crackers. 4. administer glucagon. Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) action should be taken prior to notifying the physician (2) does not require validation, implementation required (3) correct—onset of action for regular insulin is 30–60 minutes; assessment indicates a problem with hypoglycemia; foods such as milk and crackers should be given if blood sugar is around 40–60 mg/dL; if orange juice or simple sugar is given, it should be followed with a meal or with protein intake (4) unnecessary, unless client is unresponsive 23. An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST? 1. Observe the child at mealtime. 2. Inquire about the child’s eating patterns. 3. Weigh the baby each month. 4. Attempt to feed the baby for the mother. Strategy: Answers are a mix of assessments and implementations. Is validation required? Yes. (1) correct —assessment; will provide the most information (2) assessment; may or may not secure an accurate picture (3) assessment; weight should be obtained more often or on each visit (4) implementation; need to assess before determining appropriate interventions 24. A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions? 1. Administer PRN benztropine mesylate (Cogentin) immediately. 2. Hold the chlorpromazine and notify the medical staff stat. 3. Place the client in isolation on bedrest in semi-Fowler’s position. 4. Administer acetaminophen 500 mg and place the client on a cooling mattress. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) bromocriptine (Parlodel) or dantrolene (Dantrium) is used for CNS toxicity (2) correct—client is experiencing neuroleptic malignant syndrome; fatal in about 15–20% of cases; is toxic effect of antipsychotic medication (3) isolation is unnecessary (4) is not most important; cooling blanket is used for fever, IV fluids for hydration, airway if necessary, frequent monitoring of vital signs 25. A 32-year-old man comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should 1. document the findings in the chart. 2. call the physician about orders to adjust the insulin dosage. 3. give him 15 g of carbohydrates. 4. ask him to list the foods he has eaten in the last 24 hours. Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer choice. (1) correct—results normal, indicates good control of diabetes (2) no adjustments need to be made (3) does not reflect hypoglycemia (4) no adjustment needs to be made in diet; result is not altered by intake day before test 26. A school-aged child informs the school nurse that his right knee “doesn’t feel right.” Which of the following actions should the nurse take FIRST? 1. Instruct the child to extend the right leg. 2. Put both of the child’s legs through range-of-motion. 3. Advise the child to soak the right knee in warm water. 4. Compare the appearance of the right knee with the left knee. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) will not help determine if the knee is edematous (2) inspection first step of physical assessment (3) implementation; need to assess to determine the problem (4) correct—should compare corresponding joints for symmetry and to determine normal parameters 27. The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed? 1. The client’s output is 1500 cc of clear straw-colored urine. 2. The client is unable to state his name. 3. The client denies numbness and tingling. 4. The client loses 3 pounds in one week Strategy: Determine how each answer relates to hypoparathyroidism. (1) important to monitor, but are not top priority (2) confusion and decreased memory are symptoms of hypercalcemia (3) correct—tetany is major sign of hypoparathyroidism (4) most frequently observed with hyperparathyroidism 28. The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST? 1. A two-day-old infant, lying quietly alert, heart rate of 185 bpm. 2. A one-day-old infant, crying, and the anterior fontanel is bulging. 3. A 12-hour-old infant, held by the mother, respirations 45 and irregular. 4. A five-hour-old infant, sleeping, hands and feet are blue bilaterally. Strategy: Eliminate the stable patients. (1) correct—infant has tachycardia; normal resting rate is 120– 160; requires further investigation (2) crying causes increased intracranial pressure, causes fontanel to bulge (3) normal respiratory rate is 30–50 breaths per minute with apneic episodes (4) acrocyanosis is normal for 2–6 hours post delivery due to poor peripheral circulation 29. The nurse plans care for a 36-year-old woman with Graves’ disease. The nurse knows that which of the following foods or fluids should be restricted for this client? 1. Milk. 2. Apples. 3. Orange juice. 4. Tea. Strategy: Think about each answer. (1) not limited for Graves’ disease (2) not limited for Graves’ disease (3) not limited for Graves’ disease (4) correct—stimulant that would increase metabolic rate 30. After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority? 1. Decrease IV fluids. 2. Assess the fetal heart monitor. 3. Place the mother on her right side. 4. Obtain the blood pressure. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; client must be well hydrated before and after the procedure (2) assessment; may be done as ongoing management, but is not a priority (3) implementation; laboring mother would be placed on left side to promote uterine perfusion (4) correct—assessment; side effect of an epidural is hypotension from the vasodilation that occurs 31. A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication? 1. “I can take it whenever I feel upset.” 2. “I should not take this with anything but water.” 3. “I guess I need to stop drinking white wine.” 4. “This medication will help me forget and go on.” Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) indicates a need for further medication teaching (2) indicates a need for further medication teaching (3) correct—sedative drugs should not be taken with alcoholic beverages (4) indicates a need for further medication teaching 32. The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly “transferred herself to the floor.” Which of the following actions, if taken by the nurse, is BEST? 1. Place the call light within the client’s reach. 2. Remove the footrests from the wheelchair. 3. Observe the client trying to rise from a sitting to a standing position. 4. Place a posey vest restraint on the client. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; assumes that client can’t reach the call light (2) implementation; assumes that client is tripping on the footrest (3) correct— assessment; nurse can determine if client is safe to perform this activity. (4) implementation; must exhaust all other interventions before restraining client 33. A client had a thoracotomy 3 hours ago. For the past 2 hours there has been 100 cc per hour of bloody chest drainage. Which of the following actions should the nurse take FIRST? 1. Increase the IV fluid rate. 2. Administer oxygen at 5 L/min per oxygen mask. 3. Elevate the head of the bed. 4. Advise the physician of the amount of drainage. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) may be appropriate after the physician is notified (2) may be appropriate after the physician is notified (3) may be appropriate after the physician is notified (4) correct—chest drainage of 100 cc/hr is abnormal; physician should be notified 34. While a client is receiving TPN, it is MOST important for the nurse to monitor 1. vital signs and level of consciousness. 2. arterial blood gases and liver enzymes. 3. serum glucose and electrolytes. 4. skin turgor and daily weights. Strategy: “MOST important” indicates a priority question. (1) most common complications involve fluid and electrolytes (2) abnormalities in liver function may occur, but most common complications involve fluid and electrolytes (3) correct—hyperglycemia can cause diuresis and excessive fluid loss; should check fingerstick blood sugar every 6 h, check serum electrolytes (sodium, potassium, calcium, magnesium, phosphates) several times a week (4) not most important; should assess skin turgor to check for dehydration and weigh daily 35. The physician prescribes sulfisoxazole (Gantrisin) 2 g PO qid for a client. Which of the following instructions is MOST important for the nurse to include when teaching the client about this medication? 1. “Drink plenty of fluids.” 2. “Wear sunscreen when outdoors.” 3. “Eliminate dairy products from your diet.” 4. “Take this medication with meals.” Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—prevents crystalluria and stone formation (2) sun sensitivity not seen with this medication (3) no dietary restrictions with medication (4) if given with meals, it delays but doesn’t interfere with amount of medication absorbed 36. The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare? 1. A 15-year-old who vaginally delivered a 7-lb male two days ago. 2. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago. 3. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping. 4. A 22-year-old who delivered by cesarean section and is complaining of burning on urination. Strategy: Eliminate the most stable patients. (1) stable situation, no indication of problems with mother or baby (2) stable situation, no indication of problems with mother or baby (3) stable patient, cramping due to uterine contractions (4) correct—unstable patient, indicates urinary tract infections; requires follow-up 37. The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia? 1. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established. 2. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia. 3. Assess the client for any allergies to Betadine or iodine preparations. 4. Determine the specific gravity of the urine and prepare the client for insertion of a central line. Strategy: Answers are a mix of assessments and implementations. Do the assessments make sense? No. (1) correct—implementation; important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated (2) implementation; unnecessary for client to be NPO for 12 hours (3) assessment; unnecessary, as iodine dyes are not used (4) assessment/implementation; irrelevant to the procedure 38. A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period? 1. Position the client on the right side with the head slightly elevated. 2. Place the client on the left side to protect the eye. 3. Perform sensory neurological checks every two hours. 4. Maintain complete bedrest for the first 48 hours. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—should be positioned on back or unaffected side to prevent trauma to surgical eye (2) should be positioned on unaffected side (3) unnecessary for cataract clients (4) unnecessary for cataract clients 39. A 48-year-old woman is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor the patient’s 1. complete blood count (CBC). 2. temperature. 3. specific gravity of urine. 4. intracranial pressure. Strategy: “MOST important” indicates that this is a priority question. Determine what each assessment measures and how it relates to the situation. (1) not affected by surgery (2) controlled by the medulla, not the pituitary (3) correct—lack of ADH from pituitary will cause diabetes insipidus and diuresis with very low specific gravity (4) surgery performed through nose; does not affect cerebral pressure 40. A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements? 1. “I should not operate heavy machinery.” 2. “I should drink only drink five glasses of liquid per day.” 3. “This medication will cause my urine to turn orange.” 4. “I should eat dried apricots each day.” Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) medication does not cause drowsiness (2) there are no specific restrictions on fluid at this time (3) does not occur (4) correct—continued use of this diuretic may cause a loss of potassium; dietary intake of foods such as bananas or dried apricots, which are high in potassium, should be encouraged 41. A LPN/LVN contacts the nurse to say that s/he has shingles on her/his back. Which of the following statements by the nurse is BEST? 1. “You can’t take care of clients for fourteen days.” 2. “Come to work as scheduled.” 3. “You can’t care for clients until the lesions are crusted.” 4. “Please contact your physician.” Strategy: The topic of the question is unstated. Read answer choices for clues. (1) staff with localized lesions can care for non–high risk clients (2) correct—able to care for non–high risk clients; cover lesions (3) can’t care for immunosuppressed clients until lesions have crusted (4) passing the buck 42. The infant of a diabetic mother has a blood glucose of 90 mg/dL and a serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV? 1. Insulin. 2. Glucose. 3. Phenobarbital. 4. Calcium gluconate. Strategy: Determine the action of each drug and how it relates to the lab values. (1) would be given for blood sugar problems (2) would be given for blood sugar problems (3) not appropriate for a neonate (4) correct—hypocalcemia causes tetany; calcium gluconate will replace the calcium 43. The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks? 1. Use a blood pressure cuff that overlaps the arm at least four inches. 2. Support the client’s arm above the leve [Show Less]
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