NCLEX 10,000 QUESTIONS AND ANSWERS 2022/2023
LATEST UPDATE SOLUTION
The best indicator that the client has learned how to give an insulin
... [Show More] self-injection
correctly is when the client can:
a. perform the procedure safely and correctly
b. critique the nurse's performance of the procedure
c. explain all of the steps of the procedure correctly
d. correctly answer a post-test about the procedure - ANS-a - the nurse should
judge that learning has occurred from evidence of a change I the client's behavior. A
client who performs a procedure safely and correctly demonstrates that he has
acquired a skill. Evaluation of this skill acquisition requires performance of that skill
by the client with observation by the nurse. The client must also demonstrate
cognitive understanding, as shown by the ability to critique the nurse's performance.
Explaining the steps demonstrates of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae.
Which nursing assessment finding most supports this diagnosis?
a. hypoactive bowel sounds
b. severe lower back pain
c. sensory deficits in one arm
d. weakness and atrophy of the arm muscles - ANS-b - the most common finding in
a client with a herniated lumbar disk is severe lower back pain, which radiates to the
buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause
sensory and motor loss (such as foot drop) in the area innervated by the
compressed spinal nerve root. During later stages, it may cause weakness and
atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse
should do which of the following?
a. contact the client's audiologist
b. cleanse the hearing aid ear mold in normal saline
c. irrigate the ear canal
d. check the hearing aid's placement - ANS-d - inadequate amplification can occur
when a hearing aid is not place properly. The certified audiologist is licensed to
dispense hearing aids. The ear mold is the only part of the hearing aid that may be
wash frequently; it should be washed daily with soap and water. Irrigation of the ear
canal is done to remove impacted cerumen or a foreign body
The physician ordered IV naloxone (Narcan) to reverse the respiratory depression
from morphine administration. After administration of the naloxone the nurse should:
a. check respirations in 5 minutes because naxolone is immediately effective in
relieving respiratory depression
b. check respirations in 30 minutes because the effects of morphine will have worn
off by then
c monitor respirations frequently for 4 to 6 hours because the client may need
repeated doses of naloxone
d. monitor respirations each time the client receives morphine sulfate 10 mg IM -
ANS-c - the nurse should monitor the client's respirations closely for 4 to 6 hours
because naloxone has a shorter duration of action than opioids. The client may need
repeated doses of naloxone to prevent or treat a recurrence of the respiratory
depression. Naloxone is usually effective in a few minutes; however, its effects last
only 1 to 2 hours and ongoing monitoring of the client's respiratory rate will be
necessary. The client's dosage of morphine will be decreased or a new drug will be
ordered to prevent another instance of respiratory depression.
when caring for a client after a closed renal biopsy, the nurse should:
a. maintain the client on strict bed rest in a supine position for 6 hours
b. insert an indwelling catheter to monitor urine output
c. apply a sandbag to the biopsy site to prevent bleeding
d. administer IV opioid medications to promote comfort - ANS-a - after a renal
biopsy, the client is maintained on strict bed rest in a supine position for at least 6
hours to prevent bleeding. If no bleeding occurs, the client typically resumes general
activity after 24 hours. Urine output is monitored, but an indwelling catheter is not
typically inserted. A pressure dressing is applied over the site, but a sandbag is not
necessary. Opioids to control pain would not be anticipated; local discomfort at a
biopsy site can be controlled with analgesics.
a nurse is caring for a client who required chest tube insertion for a pneumothorax.
To assess for pneumothorax resolution, the nurse can anticipate that the client will
require:
a. monitoring of arterial oxygen saturation (SaO2)
b. arterial blood gas (ABG) studies
c. chest auscultation
d. chest x ray - ANS-d - chest x ray confirms diagnosis by revealing air or fluid in the
pleural space. SaO2 values may initially decrease with a pneumothorax but typically
return to normal within 24 hours. ABG studies may show hypoxemia, possibly with
respiratory acidosis and hypercapnia but these are not necessarily related to a
pneumothorax. Chest auscultation will determine overall lung status, but it's difficult
to determine if the best has re-expanded sufficiently.
To prevent development of peripheral neuropathies associated with isoniazid
administration, the nurse should teach the client to:
a. avoid excessive sun exposure
b. follow a low-cholesterol diet
c. obtain extra rest
d. supplement the diet with pyridoxine (vitamin B6) - ANS-d - isoniazid competes for
the available vitamin B6 in the body and leaves the client at risk for developing
neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely
prescribed to address this issue. Avoiding sun exposure is a preventative measure to
lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's
risk of developing atherosclerotic plaque. Rest is important in maintaining
homeostasis but has no real impact on neuropathies.
A nurse is documenting a variance that has occurred during the shift, and this report
will be used for quality improvement to identify high-risk patterns and potentially
initiate in-services programs. This is an example of which type of report?
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