Kaplan Nclex Exam 3 - intake for the next three days. Which of the fo...

Kaplan Nclex Exam 3

• A client has a total laryngectomy with a permanent tracheostomy. The nurse is planning nutritional

intake for the next three days. Which of the following would be necessary for the nurse to consider regarding the client’s nutrition?

• To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be

implemented.

• The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
• Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the

incidence of aspiration.

• Since the client is dependent on the ventilator, nutritional intake will be delayed.
• The nurse is caring for a client who presents with confusion, mood lability, impaired communication,

and lethargy. The nurse should question which of the following orders?

• Dexamethasone suppression test. 2. Thyroid studies.
• Drug toxicology screen. 4. Trendelenburg test.
• For a client with a neurological disorder, which of the following nursing assessments will be MOST

helpful in determining subtle changes in the client’s level of consciousness?

• Client posturing. 2. Glasgow coma scale.
• Client thinking pattern. 4. Occurrence of hallucinations.
• The nurse is conducting a physical examination of a client suspected to have bulimia. Which of the

following observations by the nurse would MOST likely indicate bulimia?

• The client has edema of the lower extremities.
• Physical exam of the client reveals the presence of lanugo.
• The client has ulcerated mucous membranes of the mouth.
• The client has dry, yellowish color of the skin.
• The nurse is preparing to begin a dopamine (Intropin) infusion on a client. Before beginning the infusion

the nurse should

• evaluate the urine output. 2. obtain the client’s weight.
• determine the patency of the IV line. 4. measure pulmonary artery pressures.
• The nurse is assisting a nursing assistant provide a bed bath to a comatose patient who is incontinent.

The nurse should intervene if which of the following actions is noted?

• The nurse assistant answers the phone while wearing gloves.
• The nursing assistant log rolls the patient to provide back care.
• The nursing assistant places an incontinence pad under the patient.
• The nursing assistant positions the patient on the left side, head elevated.
• A client is going to be taking imipramine (Tofranil) at home following discharge. The nurse should

instruct the client to report which of the following immediately to the nurse?

• Sore throat, fever, increased fatigue, vomiting, diarrhea.

Kaplan Nclex Exam 3

• Dry mouth, nasal stuffiness, weight gain.
• Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
• Weakness, staggering gait, tremor, feeling of drunkenness.
• The nurse has just received report from the previous shift. Which of the following patients should the

nurse see FIRST?

• A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular (AV) wires

removed later in the day.

• A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
• A patient who is one-day postoperative and has an epidural catheter in place.
• A cardiac patient who is being evaluated for a heart transplant.
• An 8-year-old girl has a closed transverse fracture of her right ulna. Which of the following actions, if

performed by the nurse before the application of a cast, is MOST important?

• Check the radial pulses bilaterally and compare.
• Evaluate the skin temperature and tissue turgor in the area.
• Assess sensation of each foot while the girl closes her eyes.
• Apply baby powder to decrease skin irritation under the cast.
• The nurse is caring for a multipara client who delivered a female infant one hour ago. The nurse

observes that the client’s breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?

• Perform a straight catheterization. 2. Offer the client the bedpan.
• Put the baby to breast. 4. Massage the uterine fundus.
• The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a

client. Which of the following results would indicate to the nurse that the tube feeding can begin?

• A small amount of white mucus is aspirated from the NG tube.
• The pH of the contents removed from the NG tube is 3.
• No bubbles are seen when the nurse inverts the NG tube in water.
• The client says he can feel the NG tube in the back of his throat.
• The nurse is caring for a client after right cataract surgery. The nurse would intervene in which of the

following situations?

• Client is in the supine position. 2. The head of the bed is elevated 30°.
• The client is lying on her right side. 4. An eye shield is over the right eye.
• A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining

abdominal wound, and diarrhea. Based on the nursing assessment, an appropriate priority nursing diagnosis is

• risk for constipation related to immobilization.
• risk for impaired skin integrity related to immobilization and secretions.
• risk for wound infection related to involuntary bowel secretions.

Kaplan Nclex Exam 3

• risk for fluid volume excess related to secretions.
• The nurse is caring for a client one day after a thoracotomy. Nursing actions on the care plan include:

turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to

• promote ventilation and prevent respiratory acidosis.
• increase oxygenation and removal of secretions.
• increase pH and facilitate balance of bicarbonate.
• prevent respiratory alkalosis by increasing oxygenation.
• The mother of a seven-year-old child is dying. The nurse should anticipate that the seven-year-old

child would have which of the following concepts of death?

• Death is punishment for his/her actions.
• Death is inevitable and irreversible.
• Death is temporary and gradual.
• Death as a concept based on past experience.
• A 46-year-old man with newly diagnosed diabetes mellitus says to the nurse, “I know that I have to

take good care of my feet. When I buy new shoes, is there anything special I should do?” Which of the following responses by the nurse is BEST?

• “It is best to buy new shoes in the morning.”
• “Have each foot measured every time you buy new shoes.”
• “Buy shoes one half size larger than your foot size so the fit is roomy.”
• “Buy vinyl shoes because they won’t lose their shape easily.”
• A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the

nursery. Because her mother is a type I diabetic, the nurse knows the infant is at GREATEST risk for developing

• hypovolemia. 2. hypoglycemia.
• hyperglycemia. 4. cold stress.
• The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year- old

girl. After the cast is applied, the nurse should

• petal the edges of the cast to prevent irritation.
• elevate the client’s left arm on two pillows.
• apply cool, humidified air to dry the cast.
• ask the client to move her fingers to maintain mobility.
• The nurse is caring for patients on the pediatric unit. The mother of a two-year-old who is one-day

postoperative tells the nurse, “My child is so restless and overactive.” The nurse should

• direct the LPN/LVN to obtain the child’s vital signs.
• ask the mother if the child’s sutures are still intact.
• tell the nursing assistant to take the child for a walk.
• check to see when the child last received pain medication.

Kaplan Nclex Exam 3

• The nurse is planning a diet for an eight-year-old with cystic fibrosis (CF). Which of the following

dietary requirements should be considered?

• High protein, high fat, and high calories.
• High protein, low fat, and high calories.
• Low protein, low fat, and low carbohydrate.
• High protein, high fat, and low carbohydrate.
• A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid

phosphatase test are to be done. The nurse knows that

• these tests are valuable screening tests for prostatic cancer.
• the level of PSA is decreased in clients with renal stones.
• the test reflects the level of renal involvement in acid-base problems.
• the level of PSA is elevated in clients in early stage renal failure.
• A client who has clear lung sounds and unlabored breathing is receiving aminophylline IV. Which of

the following would be the MOST appropriate nursing action if the client’s IV infiltrates?

• Apply warm soaks to the infiltration site, start a new IV, and continue IV medications.
• Wait two hours, reassess the client, and restart the IV if the client has wheezing or labored breathing.
• Restart the IV and continue the previous medication schedule.
• Call the physician and recommend that the IV medications be changed to PO.
• A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior. An

INITIAL nursing priority is to

• provide adequate hygiene and nutrition.
• decrease environmental stimuli.
• slowly involve the client in unit activities.
• administer and monitor sedative and mood-stabilizing medications.
• A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The

nurse would expect the patient to make which of the following statements about her symptoms?

• “I have been having difficulty with my hearing.”
• “I lose my balance easily.”
• “I can’t tell the difference between a sweet and sour taste.”
• “It is not easy for me to remember names and faces.”
• Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
• A fat-free meal the evening prior to the examination and radiopaque tablets at bedtime.
• Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
• Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4.

Explaining the importance of following directions regarding voiding during the test.

• A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The

client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and Kaplan Nclex Exam 3