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
... [Show More] hospital. 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]