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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX-RN Practice Questions For 2...Teacher 33 terms TutorDkPreview PEARS 199 term Can A nurse is planning care for a patient with anorexia nervosa. Which goal is most appropriate for the initial plan of care?

• The patient will express satisfaction with body image within one week.
• The patient will engage in social activities with peers during meal times.
• The patient will independently plan and prepare all meals.
• The patient will gain a specified amount of weight each week as agreed upon by the healthcare team.

After a transfusion, the body reacts by destroying the transfused red blood cells. What is this reaction?

• Rh negative
• antihistamine
• hemolytic
• antibody
• Hemolytic

RATIONALE: A hemolytic reaction occurs when the body destroys transfused red blood cells.

The nurse prepares to perform the initial assessment on a school-age client. The client has an open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the nurse take?

• Wear gloves only.
• Wear gown and gloves.
• Wear gown, gloves, and mask.
• No precautions are necessary.
• Wear gown and gloves.

RATIONALE: MRSA requires contact precautions. The nurse should wear clean, nonsterile gloves and gown when entering the client?s room and when having any contact with the client or with surfaces that the client touches.The nurse has four phone messages. Which message does the nurse return first?

• An older adult client undergoing bowel prep and reporting watery diarrhea.
• A client with a newborn and experiencing breast engorgement.
• A client who had a cataract extraction 3 days ago and reporting nausea.
• A client diagnosed with a C6 spinal cord injury and reporting a headache.
• A client diagnosed with a C6 spinal cord injury and reporting a headache.

RATIONALE:

A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most unstable and is experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which option is the best gift for the nurse to recommend?A)Perfume and makeup.B)Hearing aid with batteries.C)Warming tray for food.D)Quilt and soft pillow.

• Warming tray for food

RATIONALE: Warming trays can keep food hot, safe, and appealing during the slow eating process of the client diagnosed with Parkinson disease. Eating is slow because of overall slowed body movement, tremors, difficulty chewing and swallowing, fatigue, and need for rest periods. This choice directly addresses a physiologic need.The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary?

• "My child likes sleeping on the top bunk when visiting grandparents."
• "My child sleeps on a zippered covered pillow and mattress."
• "My child changes his clothes after playing outside."
• "My child wears a mask while I vacuum the carpets."

A.”My child likes sleeping on the top bunk when visiting grandparents."

RATIONALE:

Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust mites. The child is not to sleep or lie down on upholstered furniture. Use furniture that can be wiped with a damp cloth such as wood, plastic, vinyl, or leather.

The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid, rifampin, and pyrazinamide. Which client statement requires further assessment by the nurse?

• "I have gained 5 pounds since I started taking the medication."
• "I cover my nose and mouth when I cough or sneeze."
• "I drink a glass of wine with dinner each night."
• "I have stopped eating tuna salad sandwiches."
• “I drink a glass of wine with dinner each night."

RATIONALE:

An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when taking the medication.

RATIONALE FOR INCORRECT ANSWERS:

"I have gained 5 pounds since I started taking the medication." Weight loss is a symptom of TB. Gaining weight indicates the client is able to eat and is having minimal GI upset due to the medications."I cover my nose and mouth when I cough or sneeze." Covering the mouth and nose when coughing or sneezing is good hygiene and prevents the spread of disease."I have stopped eating tuna salad sandwiches." A client taking these medications should avoid tuna, aged cheese, red wine, and yeast extracts, as they may cause the adverse effects of flushing, hypotension, palpitations, and diaphoresis.The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse?

• Redness and swelling with fluid-filled vesicles noted on right arm.
• Charred, waxy, white appearance of skin on the left leg.
• Reddened blotchy painful areas noted on the trunk.
• Blistering and blanching of the skin noted on the back.
• Charred, waxy, white appearance of skin on the left leg.

RATIONALE:

This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved. The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal spontaneously and require grafting. All functions of the skin are lost.

RATIONALE FOR INCORRECT ANSWERS:

• This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large, thick-walled blisters develop, and the

underlying tissue is deep red and appears wet and shiny. The damaged skin is painful with increased sensitivity to heat. Healing occurs by evolution of undamaged basal cells and takes about 21 to 22 days.

• This describes a superficial burn. The skin appears pink and has increased sensitivity to heat. Healing occurs without treatment.

D)This describes a partial-thickness burn.

The nurse providing care for clients with diabetes mellitus receives report. Which client does the nurse see first?

• A female client who reports urinary frequency and burning with urination.
• A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch.
• A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst.
• A client who reports experiencing constant hunger.
• A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch.

RATIONALE:

The lower blood pressure and hot, dry skin indicate dehydration caused by hyperglycemia. This is the first stage of diabetic ketoacidosis (DKA).This client has a circulatory concern and is the highest priority.The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first?

• Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped.
• Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate.
• Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days.
• Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red.
• Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red.

RATIONALE:

A moist and red umbilical cord stump in a client of this age indicates an infection or other problem with the umbilical stump. The cord should be dry and without redness.The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which current client is best for immediate discharge?A)An older adult client admitted 4 days ago with a diagnosis of a stage 3 pressure injury.

• An older adult client admitted 12 hours ago with a diagnosis of pyelonephritis.
• An older adult client 3 days postoperative after a total hip replacement.
• An adult client 24 hours postoperative after a vaginal hysterectomy.
• An older adult client 3 days postoperative after a total hip replacement.

RATIONALE:

This is the most stable client. Clients post-total hip replacement are typically discharged on postoperative day 2 to 3 to a rehab facility or home.The home care nurse visits a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse instructs the client's caregiver about how to prevent infection. Which is the most important instruction the nurse will give to the caregiver?

• "Cover your nose and mouth when you sneeze or cough."
• "Get rid of all pets in the home."
• "Wash your hands frequently."
• "Wash the client's dishes separately."
• “Wash your hands frequently."

RATIONALE:

Hand hygiene is the single best way to kill germs. The caregiver should wash hands after going to the bathroom and before and after fixing food. The caregiver should also wash hands before and after caring for the client.