Kaplan NCLEX Questions and answers| Graded A
A client with type 1 diabetes returns to the recovery room one hour after an uneventful delivery of a 9lb,
... [Show More] 8oz newborn. The nurse would expect the client's blood glucose level to change from which of the following?
1. 220 to 180 mg/dl
2. 110 to 80 mg/dL
3. 90 to 120 mg/dL
4. 100 to 140 mg/dL Correct Answer: 2. 110 to 80 mg/dL
Which of the following assignments by the RN would be appropriate for an LPN/LVN?
1. A client with low back pain scheduled for a myelogram
2. A client in traction for treatment of a fractured femur
3. A client newly diagnosed with type 1 diabetes
4. A client with emphysema scheduled for discharge Correct Answer: 2. The client in traction is in stable condition and can be cared for by an LPN
After receiving a HOC report from the nurse on the prior shift, which of the following clients should the nurse see first?
1. A client refusing to take sucralfate before mealtime.
2. A client with left-sided weakness asking for assistance to the commode
3. A client reporting chills who is scheduled for a cholecystectomy.
4. A client with a nasogastric tube who had a bowel resection yesterday Correct Answer: 3. A client reporting chills who is scheduled for a cholecystectomy is least stable
The primary health care provider prescribes tobramycin sulfate 3mg/kg IV every 8 hours for a 3 year old clilent. The nurse enters the client's room to administer the medication and discovers that the client does not have an identification bracelet. Which of the following actions should the nurse take?
1. Ask the parents to state their child's name.
2. Ask the child to say the first and last name.
3. Have a coworkers identify the child before giving the medication.
4. Hold the medication until an identification bracelet can be obtained Correct Answer: 1. Asking the parents to state their child's name will allow the nurse to correctly identify the child and enable the nurse to give the medication on time.
A client in active labor is admitted to the labor suite. An hour later, the client experiences spontaneous rupture of membranes. The nurse observes a glistening white umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?
1. Return to the nurses' station and call the primary HCP
2. Administer oxygen by mask at 10-12 L/minute and assess vital signs
3. Place a clean towel over the umbilical cord and wet it with sterile normal saline solution
4. Apply manual presssure to the presenting part and have the lcient assume a knee-chest position Correct Answer: 4. Apply pressure. Umbilical cord prolapse is an emergency situation. The nurse must relieve pressure on the umbilical cord to prevent fetal anoxia.
Most effective approach by nurse for verbally abuse patient who demands to go to cafeteria for food? Correct Answer: Calmly but firmly escort the client back to client's room. The nurse should not reinforce abusive behavior. Clients need consistent and clearly defined expectations and limits
Most essential care for a client with a cast? Correct Answer: Check circulation in the casted extremity.
Venipuncture site for dextrose 5% Correct Answer: Dorsal surface vein of the nondominant forearm
Expected lab result for diabetic ketoacidosis? Correct Answer: Blood pH 7.28
Best action for delivering CPR Correct Answer: Position hands on the lower half of the sternum during compressions
Significant history finding for client with acute glomerulonephritis? Correct Answer: Personal history of sore throat 10 days prior. Glomerulopnehphritis is an immunologic disorder that affects the kidneys. can be caused by group A streptococcus. Usually occurs about 10 days after strep throat or scarlet fever and about 21 days after a group A Streptococus skin infecition.
Most appropriate nursing diagnosis for a client with MI, reporting fatigue, clammy skin, prolonged capillary refill, oliguria? Correct Answer: Impaired cardiac output
What should be done first for client with nausea, vomiting, severe right upper quadrant pain, with temp of 101.3, enlarged gallbladder, and schedule for surgery.
1. Assess client's need for dietary teaching
2. Evaluate the client's fluid and electrolyte status
3. Examine the client's health history for allergies to antibiotics
4. Determine whether the client has signed consent for surgery Correct Answer: 2. Evaluate the client's fluid and electrolyte status. Hypokalemia and hypomagnesemia commonly occur after repeated vomiting
Best way to apply silver sulfadizine cream application for client with second and third degree burns over 45% of the body Correct Answer: Sterile, gloved hand will cause least trauma to tissues and decrease the chances of breaking tissues, as opposed to using tongue depressors, cotton tipped applictors, and dressings soaked in saline
Indication that client's condition of anorexia nervosa is imporving? Correct Answer: The client has gained weight
Most important to assess for a client who complains of suspected pacemaker battery failure? Correct Answer: Palpitations, SOB, and dizziness
Which of the following symptoms observed by the nurse during the first 24 hours after a percutaneous liver biopsy would indicate a complication from the procedure?
1. Anorezia, nausea, vomiting
2. Ab distention and discomfort
3. Pulse 112 beats/minute and BP 86/60 mHg
4. Redness and pain at the biopsy site Correct Answer: Complication= hemorrhagin
sx of hemorrhage is answer 3 (increased pulse and decreased BP)
Any diet restrictions for haloperidol Correct Answer: No. IF questions hints that it may, pick the regular, balanced adult diet
Hot spots of chest Correct Answer: 1. Tricuspid area: 4th and 5th intercostal spaces at the lower left of the sternal border
2. Angle of Louis: manubrial sternal junction at the second rib
3. Aortic area: second intercostal space to the right of the sternum
4. Pulmonic area: second intercostal space to the left of the sternum
5. Erb's point: 3rd intercostal space to the left of the sternum
6. Mitral are: 5th intercostal space at the left midclavicular line
Order of steps of any procedure Correct Answer: 1. prepare the client
2. prepare the equipment
3. apply equipment to client
Example of order of steps of procedure (urinary catheter) Correct Answer: 1. Place client supine with knees flexed
2. Open the sterile pack between client's legs
3. Put on sterile gloves
4. Inflate balloon of the catheter to check for leaks
5. Lubricate the tip of the catheter
6. Wipe the urinary meatus with a cotton ball saturated with cleansing solution
An agitated patient who was just sedated should not remain alone Correct Answer: Assign an LPN/LVN to remain with cleint. Not a security guard, not alone, and not restrained with your coworker either like we do in the real world
A non-breastfeeding mother should NOT Correct Answer: pump breasts because this would stimulate milk production
A non-breastfeeding mother SHOULD Correct Answer: 1. wear a tight bra and apply ice packs to relieve engorgement discomfort
2. take presribed pain medication when in pain or discomfort
3. take prescribed pills to stop production of milk (though not frequently prescribed due to dangerous side effects)
The nurse would expect the primary HCP to prescribe which of the following lab tests for a client whose digoxin dose was increased last month? The client has taken furosemide and digoxin for 3 years every day Correct Answer: serum electrolyte (furosemide causes hypokalemia, which increases the risk for digitalis toxicity) and digoxin levels [Show Less]