Kaplan Nclex Exam 5 - the following questions is the MOST important f...

1 Kaplan Nclex Exam 5

• The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of

the following questions is the MOST important for the nurse to ask?

• “Did you have anything to eat or drink before you came in today?”
• “Have you had any headaches since your last treatment?”
• “Who came with you to the hospital today?”
• “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 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client

about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?

• Lemonade.
• Prune juice.
• Milk.
• Orange juice.

Strategy: “Teaching was effective” indicates you are looking for a true statement. (1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk, 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 promotes alkaline urine (4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and carbonated beverages

• The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST

important for the nurse to include which of the following as a part of his discharge planning?

• Referral to a social service agency for assistance with housing.
• Referral to an aftercare center in the community.
• Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
• 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) unnecessary

• A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his

first injection. Which of the following responses by the nurse is BEST?

• “A booster shot is required yearly.”
• “Additional injections are given at one and six months.”
• “Repeat doses are given at two and four months.”
• “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 one and six months (3) schedule for infant immunizations for OPV and DPT (4) inaccurate Kaplan Nclex Exam 5

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• The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with

an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?

• Change the IV tubing each time a new IV solution is hung.
• Cleanse the IV site with an alcohol swab using long strokes.
• Limit manipulation of the cannula at the IV insertion site.
• 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 48–72 hrs (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?

• Send the staff member home.
• Assess the staff member’s compliance with standard precautions.
• Assign the staff member only to clients with chronic diseases.
• Re-assign 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 3–7 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 is planning 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?

• Monitor the client’s ability to complete her activities of daily living (ADL).
• Assess the client’s levels of pain and correlate it with her response to analgesia.
• Observe the client’s behavior at regular intervals to obtain baseline information related to her

screaming.

• 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

• Preparation for the Nursing Licensure Examination 8. The nurse observes a student nurse checking the

placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?

• Places the end of the NG tube in a cup of water and watches for bubble formation.
• Checks the pH of the contents aspirated from the NG tube.

Kaplan Nclex Exam 5

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• Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
• Uses a large barreled syringe to aspirate for stomach contents.

Strategy: “Require an intervention” indicates that you are looking for an incorrect behavior. (1) correct–not considered acceptable procedure (2) gastric contents are acidic (3) “swoosh” of air indicates proper placement (4) acceptable action

• While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST

priority?

• The medication should be taken once a day for six weeks.
• The medication should be taken with orange juice.
• The medication should be taken in the morning and at bedtime.
• 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 two to three 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 knows that teaching has been effective if

the client makes which of the following statements?

• “I will have my parents put bed-boards on my bed.”
• “I should decrease my caloric intake.”
• “I should only take tub baths.”
• “I can remove the brace for one hour a day.”

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–should be worn at all times, except when bathing

• The nurse in a long-term care facility is reviewing the nurse’s notes in a client’s chart. The nurse

would be MOST concerned by which of the following entries?

• “Foley catheter draining clear urine and the pH is 6.5.”
• “The client’s skin is blanched over the scapular areas.”
• “Vital signs are within normal limits.”
• “The client drinks three glasses of orange juice every day.”

Strategy: Remember the rules of charting. (1) appropriate charting of normal urine (2) correct–blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers (3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem (4) appropriate charting

• The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four

phone messages. Which of the following messages should the nurse return FIRST?

• A client with cold symptoms has an oral temperature of 103°F (39.4°C).
• A client with stage II decubitus ulcer reports that the dressing has come off.
• A client is nauseated and has vomited 6 times in the previous 24 hours.
• A client is complaining of leg pain after walking half a mile.

Kaplan Nclex Exam 5

4 Strategy: Eliminate the two most stable clients. Use the ABCs to determine the most unstable client. (1) elevated temperature indicates infection; determine the underlying cause, encourage fluids (2) stable client (3) correct–assess amount, character, symptoms of fluid volume deficit (4) stable client, complaint indicates intermittent claudication

• A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate

postoperative period, which of the following actions, if performed by the nurse, is BEST?

• Restart the IV above the level of the graft.
• Take blood pressures only on the right arm.
• Elevate the left arm above the level of the heart.
• Check the radial pulse on the left arm q4h. Strategy: Determine the outcome of each answer choice.

(1) IVs should not be started in the grafted arm (2) correct–BP should always be taken on the opposite arm from the graft (3) unnecessary (4) would not prevent complications, but would identify complications

• The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving

oxytocin IV to stimulate labor. The priority nursing intervention would be to

• discontinue the infusion.
• turn client to the left side.
• change the fluids to LR.
• increase the IV flow rate.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration (2) may help the deceleration, but is not a priority (3) will have no influence on the fetal heart rate (4) will have no influence on the fetal heart rate

• The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient

complains to the nurse that she has a dull ache in her left leg. The nurse should

• place the patient on bedrest and elevate the foot of the bed six inches.
• ask the patient to remain in bed and place a pillow under the knee to elevate her left leg.
• ambulate the patient as directed to prevent complications of bedrest.
• obtain thigh-high compression or elastic stockings and continue ambulating the patient.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?(1) correct–promotes venous return and decreases venous pressure relieving pain and edema (2) would obstruct venous flow increasing chance for thrombus formation (3) would cause pressure fluctuations in venous system; could cause emboli, should be on bedrest 5–7 days (4) used to prevent deep vein thrombosis, should be on bedrest initially

• A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse

specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction?

• Referral for psychopharmacologic intervention.
• Group psychotherapy.
• Systematic desensitization.
• Biofeedback.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?(1) reasonable treatment options as the nurse obtains further information (2) reasonable treatment options as the nurse obtains further information (3) correct–phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavioral modification; Kaplan Nclex Exam 5