NCLEX EXAM PREVIEW - ScienceMedicineNursing LauraAcevedo321 Save 75 ...

Exam Cram NCLEX RN Practice Questions Exam 1 ScienceMedicineNursing LauraAcevedo321 Save 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview

NCLEX EXAM PREVIEW

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NCSBN NCLEX QUESTIONS

408 terms ANNEMARIEBISHOP Preview NCLEX Teacher Tut A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?

• 1 cup beef broth
• 1 baked potato
• 1/2 cup raisins
• 1 cup rice

D (1 cup of rice)

• Answer D is correct because one cup of rice is considered a low-potassium food. The foods in answer A, B, and C are incorrect because they

contain higher amounts of potassium) An appropriate nursing intervention for the client with borderline personality disorder is:

• Observing the client for signs of depression or suicidal thinking
• Allowing the client to lead unit group sessions
• Restricting the client's activity to the assigned unit of care throughout hospitalization
• Allowing the client to select a primary caregiver

A (observing the client for signs of depression or suicidal thinking) (Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect because the client's activities do not have to be restricted to the unit after the level of depression has been determined )

Which of the following is an expected finding in the assessment of a client with bulimia nervosa

• Extreme weight loss
• Presence of lanugo over body
• Erosion of tooth enamel
• Muscle wasting

C (Erosion of tooth enamel) (Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with bulimia nervosa. Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.) Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?

• One-year-old
• Four-year-old
• Eight-year-old
• Twelve-year-old

B (Four-year-old) (Because of their increased mobility, manual dexterity and curiosity, the four year old is at greater risk for accidental poisoning. Other accidental injuries in this age group include being struck by a car, falls, burns, and drowning. Answer A is incorrect because the one-year-old lacks the developmental skill to be at risk for accidental poisoning. Answers C and D are incorrect because the eight-year-old and the twelve-year-old are at less risk because they are aware of the dangers of accidental poisoning) Which term describes the play activity of the preschool aged child?

• Cooperative
• Associative
• Parallel
• Solitary

B (Associative) (Play of the preschool aged child is described as associative. At this stage, children are more interested in playing with other children than they are with playing with toys. The child may talk to other children and exchange toys or play games without any rules. Answer A describes the play of a school-aged child. Answer C describes the play of an infant.) The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?

• Check the Babinski reflex
• Listen to the heart and lung sounds
• Palpate the abdomen
• Check tympanic membranes

B (Listen to the heart and lung sounds) (While the infant is quiet, the nurse should begin the exam by listening to the heart and lungs. If the nurse elicits the Babinski reflex , palpates the abdomen, or checks the tympanic membranes, the infant may cry and it will be difficult to adequately listen to the heart and lungs; therefore answers A,C, and D are incorrect.)

In terms of cognitive development, a three-year-old would be expected to:

• Think abstractly
• Use magical thinking
• Understand conservation of matter
• See things from the perspective of others

B (Use magical thinking) (A three-year-old is expected to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are incorrect because of abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are cognitive abilities of an older child) Which of the following describes the language development of a two-year-old?

• Doesn't understand yes and no
• Understands the meaning of all words
• Can combine three or four words
• Repeatedly asks "why?"

C (can combine three or four words) (The two year old can combine three to four words. Answers A and B are incorrect because the two-year-old understands yes and no, but does not understand the meaning of all the words. Answer D is incorrect because seeking information and asking "why?" is typical of the three-year old) A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?

• Prepare an injection of vitamin K
• Irrigate the urinary catheter with 50 mL of normal saline
• Offer the client additional oral fluids
• Withhold the medication and notify the physician

D (Withhold the medication and notify the physician) (Urokinase is a thrombolytic agent used in the treatment of deep vein thrombosis, pulmonary embolus, or myocardial infarction. The presence of dark brown or rust-colored urine suggests bleeding. The nurse should withhold the medication, call the doctor immediately, and prepare to administer Amicar. Answer A is correct because vitamin K is not the antidote for urokinase. Answers B and C are incorrect because they do not address the adverse problem of bleeding) Which of the following can occur with the frequent use of calcium based antacids?

• Constipation
• Hyperperistalsis
• Delayed gastric emptying
• Diarrhea

A (Constipation) (The client taking calcium-based antacids will frequently develop constipation. Answers B, C, and D are not associated with the use of calcium- based antacids; therefore, they are incorrect.)

Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?

• "I will administer the medication 1-2 inches away from the umbilicus."
• "I will not massage the injection site after administering the heparin."
• "I will check the PTT before administering the heparin."
• "I will need to gently aspirate when I give the heparin."

D ("I will need to gently aspirate when I give the heparin.") (The nurse should not aspirate when giving heparin; therefore, answer D indicates a need for further teaching regarding heparin administration.Answers A, B, and C indicate the student nurse understands the the correct administration of heparin and are, therefore, incorrect answers. ) To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:

• Finger
• Earlobe
• Extremity with noninvasive BP cuff
• Nose

C (Extremity with noninvasive BP cuff) (To obtain a correct oxygen saturation reading using pulse oximetry, the probe should not be placed on the arm with a noninvasive BP cuff or intraarterial line. Suitable sites are the finger, earlobe, or nose; therefore, Answers A, B, and D are incorrect.) While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 129, respirations 36. The

nurse's initial action should be to:

• Report the findings to the physician
• Recheck the vital signs in one hour
• Ask the patient if he is in pain
• Compare the current vital signs with those on admission

A (Report the findings to the physician) (The client is exhibiting a widened pulse pressure, tachycardia, tachypnea. The first nursing action after obtaining these vital signs is to notify the physician for additional orders. Answers B, C, and D can be done after the physician is notified; therefore, they are incorrect choices as a first action.) The nurse is preparing s client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid:

• Using a recliner to rest
• Resting in supine position
• Sitting in a straight chair
• Sleeping in right Sim's position

C (Sitting in a straight chair) (The client with the axillo-popliteal graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Answers A, B, and D are incorrect because resting in a supine position, resting in a recliner, and sleeping in the right Sim's position are allowed.)