BSC 2085 200question nclex exam
Question 1 See full question
A client is scheduled to have a graded exercise test. The nurse explains to the client
... [Show More]
that the test will determine how:
You Selected:
well the body reacts to controlled exercise stress.
Correct response:
well the body reacts to controlled exercise stress.
Explanation:
Graded exercise testing is a diagnostic and prognostic tool used to determine the
physiologic responses to controlled exercise stress. Information gained from a
graded exercise test can achieve diagnostic, functional, and therapeutic objectives
for the client. Graded exercise tests involve the use of a treadmill, stationary
bicycle, or arm ergometry. The information obtained from this test is not used to
set the incline on the treadmill, and measuring the distance walked and the
duration of the walk are not the purpose of a graded exercise test.
Remediation:
Electrocardiography, exercise
Question 2 See full question
A nurse should include which discharge instruction for clients receiving tricyclic
antidepressants?
You Selected:
Restrict fluid and sodium intake while using this medication.
Correct response:
Don't consume alcohol while using this medication.
Explanation:
Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry
mouth and blurred vision are normal adverse effects of tricyclic antidepressants.
Fluid and sodium intake must be monitored during lithium treatment, not during
treatment with tricyclic antidepressants. Safe use of tricyclic antidepressants during
pregnancy and breast-feeding hasn't been established.
Remediation:
Amitriptyline hydrochloride
Clomipramine hydrochloride
Question 3 See full question
The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a
client with cholecystitis who has nausea. The ampule label reads that the
medication is available in 25 mg/mL. How many milliliters should the nurse
administer? Record your answer using one decimal place.
Your Response:
0.7
Correct response:
1.4
Explanation:
The following formula is used to calculate the correct dosage:
35 mg/X = 25 mg/1 mL
X = (35/25) mL
X = 1.4 mL.
Question 4 See full question
Levothyroxine 0.2 mg orally has been prescribed for a client diagnosed with
hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should
the nurse prepare to give the client?
You Selected:
two tablets
Correct response:
four tablets
Explanation:
0.2 mg/x tablet = 0.05 mg/1 tablet.
x = 4 tablets.
Remediation:
Levothyroxine sodium
Question 5 See full question
What is the nurse’s priority intervention for a toddler who has just had a hip-spica
cast applied?
You Selected:
Assess sensation, circulation, and motion of the child’s feet and toes
Correct response:
Assess sensation, circulation, and motion of the child’s feet and toes
Explanation:
Assessing sensation, circulation, and motion is necessary in all children with a cast.
Fluids should be encouraged, and careful diapering and padding will keep the
child’s cast dry. Discharge instructions are not a priority, but should be shared at a
later time. Children experiencing pain should receive medication as needed.
Remediation:
Cast assessment and management, pediatric
Casting, pediatric
Question 6 See full question
A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How
many gtts/min should the nurse count to ensure that the fluid is safely infusing?
You Selected:
27 gtts/min
Correct response:
27 gtts/min
Explanation:
The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min
Remediation:
IV infusion, dose and flow rate calculations
Question 7 See full question
Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is
irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status,
which action would be most appropriate?
You Selected:
Give the infant small, frequent feedings.
Correct response:
Give the infant small, frequent feedings.
Explanation:
An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy,
and vomiting, which are associated with increased intracranial pressure. Small,
frequent feedings given at times when the infant is relaxed and calm are tolerated
best. Feeding an infant before any procedure is inappropriate because the stress of
the procedure may lead to vomiting. Ideally, the infant should be held in a slightly
vertical position when feeding to prevent backflow of formula into the eustachian
tubes and subsequent development of ear infections. Giving large, less frequently
feedings allows for rest, but typically results in more vomiting.
Remediation:
Ventriculoperitoneal shunt placement
Hydrocephalus, pediartic
Question 8 See full question
A 13-year-old child has seen the school nurse several times with headache,
vomiting, and difficulty walking. When calling the adolescent's mother about these
symptoms, what should the nurse suggest the mother do first?
You Selected:
Make an appointment with the adolescent's health care provider (HCP).
Correct response:
Make an appointment with the adolescent's health care provider (HCP).
Explanation:
A child who has symptoms of vomiting, headaches, and problems walking needs to
be evaluated by a health care provider (HCP) to determine the cause. Unexplained
headaches and vomiting along with difficulty walking (e.g., ataxia) may suggest a
brain tumor. Evaluation by an eye HCP would be appropriate once a complete
medical evaluation has been accomplished. Psychological counseling may be
indicated for this adolescent, but only after medical evaluation to determine that
she is physically healthy. Meeting with the child’s teachers would be appropriate
after medical evaluation.
Remediation:
Physical assessment, pediatric
Question 9 See full question
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should
serve this client:
You Selected:
tea and gelatin dessert.
Correct response:
tea and gelatin dessert.
Explanation:
A clear liquid diet consists of foods that are clear liquids at room temperature or
body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin
desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg
substitutes, and oatmeal are part of a full liquid diet.
Remediation:
Vomiting
Question 10 See full question
Clozapine therapy has been initiated for a client with schizophrenia who has been
unresponsive to other antipsychotics. The client states, "Why do I have to have a
blood test every week?" Which response by the nurse would be most appropriate?
You Selected:
"Weekly blood tests are necessary to determine safe dosage and to monitor the
effect of the medication on the blood."
Correct response:
"Weekly blood tests are necessary to determine safe dosage and to monitor the
effect of the medication on the blood."
Explanation:
The client needs specific information about the effects of the drug, specifically that
the drug can cause agranulocytosis. The statement about weekly blood tests to
determine safe dosage and monitoring for effects on the blood gives the client
specific information to ensure follow-up with the required protocol for clozapine
therapy. Lack of accurate knowledge can lead to noncompliance with necessary
follow-up procedures and noncompliance with medication. The supply of
medication is not dependent on blood testing. Telling the client that the health care
provider (HCP) wants to know the progress does not provide specific information
for this client. The blood tests are not required by the drug company.
Remediation:
Clozapine
Question 11 See full question
A nurse is caring for a client who is recovering from a myocardial infarction (MI).
The cardiologist refers him to cardiac rehabilitation. Which statement by the client
indicates an understanding of cardiac rehabilitation?
You Selected:
"Rehabilitation will help me function as well as I physically can."
Correct response:
"Rehabilitation will help me function as well as I physically can."
Explanation:
The client demonstrates understanding of cardiac rehabilitation when he states
that it helps the client reach his activity potential. Coronary artery disease, which
typically causes an acute MI, is a chronic condition that isn't cured. Many clients
who suffer an acute MI can eventually return to such activities as jogging,
depending on the extent of cardiac damage. Cardiac rehabilitation involves physical
activity as well as classroom education.
Remediation:
Myocardial infarction
Myocardial Blood Flow
Question 12 See full question
While caring for a client who's immobile, a nurse documents the following
information in the client's chart: "Turned client from side to back every 2 hours."
"Skin intact; no redness noted." "Client up in chair three times today." "Improved
skin turgor noted." Which nursing diagnosis accurately reflects this information?
You Selected:
Risk for impaired skin integrity related to immobility
Correct response:
Risk for impaired skin integrity related to immobility
Explanation:
The information documented in the client's chart reflects the risk for impaired skin
integrity. Because the client's skin is intact, the problem is only a potential one, not
an actual one, which makes the nursing diagnosis of Impaired skin integrity
inappropriate. If constipation were a problem, interventions would focus on diet
and activity. If body image disturbance were a problem, interventions would focus
on the client's feelings about himself and his disease.
Remediation:
Pressure ulcer prevention
Question 13 See full question
A nurse is caring for an older client who has had a hemorrhagic stroke. The client
has exhibited impulsive behavior and, despite reminders from the nurse, doesn't
recognize his limitations. Which priority measure should the nurse implement to
prevent injury?
You Selected:
Install a bed alarm to remind the client to ask for assistance and to alert staff
that the client is getting out of bed.
Correct response:
Install a bed alarm to remind the client to ask for assistance and to alert staff
that the client is getting out of bed.
Explanation:
The bed alarm will alert staff that the client is attempting to transfer, so they can
come to assist. The nurse shouldn't encourage the family to reprimand the client.
Instead, the nurse should ask the family to encourage the client to request
assistance. The nurse should encourage the client to use the call light in all
situations, not just emergencies. A vest and wrist restraints aren't appropriate
unless less-restrictive measures have failed and the client is a danger to himself or
others.
Remediation:
Confused patient, care of
Question 14 See full question
A nurse is caring for a client diagnosed with cardiomyopathy. The student nurse
assigned to collaborate with the nurse begins data collection for the admission
assessment. The student nurse violates information security when she:
You Selected:
writes the client's phone number on her clinical paperwork.
Correct response:
writes the client's phone number on her clinical paperwork.
Explanation:
Documenting identifying information taken outside the institution is violates
information security. The student nurse has no need for the client's phone number
on her clinical paperwork in order to provide care. Completing admission
paperwork and data collection sheets is within the scope of practice for the student
nurse and doesn't violate information security.
Remediation:
Documentation
Question 15 See full question
When obtaining a client's history, a nurse develops a genogram. What is the
purpose of developing a genogram? [Show Less]