NURSING FUNDAMENTA Kaplan NCLEX-RN Question Trainer 5 (150 Questions) 20232/4
The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive
... [Show More] (ECT) treatment. Which of the
following questions is MOST important for the nurse to ask?
1
.
"Did you have anything to eat or drink before you came in today?"
2
.
"Have you had any headaches since your last treatment?"
3
.
"Who came with you to the hospital today?"
4
.
"Have you had much memory loss since you began your treatments?"
Strategy: Determine how each answer choice relates to ECT.
(1) correct—client given general anesthesia for ECT; NPO after midnight
(2) not relevant to ECT
(3) not most important
(4) memory loss is an expected outcome
A client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client
about dietary changes. Which of the following beverages, if selected by the client, indicates to the nurse
that teaching is effective?
Select all that apply.
1
.
Lemonade.
2
.
Prune juice.
3
.
Milk.
4
.
Orange juice.
5
.
Cranberry juice.
6
.
Tomato juice.
Strategy: "Teaching is effective" indicates a correct statement.
(1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated
beverages
(2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
(3) excessive amounts of milk promote alkaline urine
(4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated
beverages
(5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
(6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use
cranberry, tomato juice, bouillon
The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for
the nurse to include which of the following as part of the discharge planning?
1. Refer to a social service agency for assistance with housing.
2. Refer to an aftercare center in the community.
3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor.
4. Ask the client to obtain a prescription for an antidepressant medication.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) may be of some help, but will not directly provide support necessary to maintain sobriety
(2) may be of some help, but will not directly provide support necessary to maintain sobriety
(3) correct—self-help groups have greatest success rate as a sustained support system in the community
(4) is information to indicate client depressed
The client comes to the clinic for hepatitis B vaccine and asks if more than one injection is necessary.
Which of the following responses by the nurse is BEST?
1
.
"A booster shot is required yearly."
2
.
"Additional injections are given at one and six months."
3
.
"Repeat doses are given at two and four months."
4
.
"Revaccination is not required."
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) yearly doses are given for flu shots, not for hepatitis B vaccine
(2) correct—hepatitis B vaccine is repeated at 1 and 6 months
(3) schedule for infant immunizations for IPV and DPT
(4) inaccurate
The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl
infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is BEST?
1
.
Change the IV tubing each time a new IV solution is hung.
2
.
Cleanse the IV site with an alcohol swab using long strokes.
3
.
Limit manipulation of the cannula at the IV insertion site.
4
.
Adjust the drop rate to keep the total volume of IV fluids on schedule.
Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. "BEST"
indicates that this is a priority question. All answers are implementations. Determine the outcome of each
answer choice. Is it desired?
(1) unnecessary, changed every 48 to 72 h
(2) should move swab in a circular motion outward
(3) correct—will prevent dislodgment of needle
(4) should give IV at rate ordered by physician, don't play "catch-up" with fluids
The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye
and the eye appears red. Which of the following actions, if taken by the nurse, is BEST?
1
.
Send the staff member home.
2
.
Assess the staff member's compliance with standard precautions.
3
.
Assign the staff member only to clients with chronic diseases.
4
.
Reassign the staff member to clean the supply closet.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) correct—extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly
contagious; infected employees cannot work until symptoms have resolved in 3 to 7 days
(2) restrict from patient contact and the patient's environment
(3) restrict from patient contact and the patient's environment
(4) cannot work
The nursing staff plans to use behavior modification techniques for an elderly woman who constantly
screams. Which of the following nursing assessments is necessary to establish a successful program?
1
.
Monitor the client's ability to complete her activities of daily living (ADL).
2
.
Assess the client's levels of pain and correlate it with her response to analgesia.
3 Observe the client's behavior at regular intervals to obtain baseline information related to her
. screaming.
4
.
Ask the client why she is screaming and document it on her nursing assessment record.
Strategy: Determine what is being assessed in each answer choice and how it relates to screaming.
(1) important because activities of daily living can contribute to the targeted behavior of screaming;
assessing only the area of ADLs does not provide comprehensive data for developing a behavior
management program
(2) important because activities of pain can contribute to the targeted behavior of screaming; assessing
only the area of pain does not provide comprehensive data for developing a behavior management
program
(3) correct—to design an effective behavior modification program, accurate baseline data must first be
collected about the target behavior in relation to frequency, amount, time, and precipitating factors
(4) client may be unable to state why she is screaming; asking "why" questions is nontherapeutic
The nurse observes a student nurse check the placement of a nasogastric (NG) tube prior to administering
an intermittent feeding. Which of the following actions, if performed by the student nurse, requires an
intervention by the nurse?
Select all that apply.
1
.
The student nurse checks the pH of the contents aspirated from the NG tube.
2
.
The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced
into the NG tube.
3
.
The student nurse uses a large-barreled syringe to aspirate for stomach contents.
4
.
The student nurse flushes the NG tube with 30 ml of air before aspirating fluid.
5
.
The student nurse places the end of the NG tube in a cup of water and watches for bubble
formation.
"Requires an intervention" indicates incorrect behavior.
(1) appropriate action; if client has for at least 4 hours, pH of gastric aspirate is 1 to 4
(2) correct—air injected to lungs, pharynx or esophagus may transmit similar sound
(3) acceptable action
(4) appropriate action; enables easier aspiration of fluid
(5) correct—not considered acceptable procedure; if tube placed in lungs, may cause bubbling
While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST
priority?
1 The medication should be taken once a day for 6 weeks.
.
2
.
The medication should be taken with orange juice.
3
.
The medication should be taken in the morning and at bedtime.
4
.
The medication should be taken with meals.
Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?
(1) is taken twice a day for 2 to 3 weeks
(2) unnecessary
(3) will cause GI upset unless taken with meals
(4) correct—will decrease GI upset
A brace is ordered for a young teen with scoliosis. The nurse determines teaching is effective if the client
makes which of the following statements?
1. "I will have my parents put bed-boards on my bed."
2. "I should decrease my caloric intake."
3. "I should only take showers."
4. "I will hold on the rail when going down the stairs."
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) bed-boards maintain proper vertebral alignment but can't correct lateral curvature of scoliosis
(2) diet should be high-calorie due to age of child and growth requirements; diet doesn't affect curvature of
the spine
(3) either tub bathing or a shower is permitted
(4) correct—prevents falls, should also avoid slippery surfaces
The nurse in a long-term care facility reviews the nurse's notes in a client's chart. The nurse is MOST
concerned by which of the following entries?
1
.
"Foley catheter draining clear urine and the pH is 6.5."
2
.
"The client's skin is blanched over the scapular areas."
3
.
"Vital signs are within normal limits."
4
.
"The client drinks three glasses of orange juice every day."
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