NCLEX MANAGEMENT OF CARE WITH REAL EXAM QUESTIONS

NCLEX MANAGEMENT OF CARE WITH REAL EXAM QUESTIONS

AND DEATAILED ANSWERS | GRADED A+ | GUARANTEED PASS |

LATEST VERSION 2024/2025

A client is having a seizure; his blood oxygen saturation drops from 92% to 82%.What should the nurse do first? - ANSWER-Open the airway - nurse needs to open the airway first when the oxygen saturation drops. The other actions might be appropriate, but the airway must be patent.

To remove a client's gown when she has an intravenous line, the nurse should: -

ANSWER-thread the bag and tubing through the gown sleeve, keeping the line intact - opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open a long sleeve, are widely available.

Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with: - ANSWER-Iron, folic acid, and B12 - the kidneys of a client in renal failure produce no erythropoietin, a hormone necessary for RBC production.Erythropoietin can be given as replacement, but the client needs adequate iron, folate, and B12 to increase the effectiveness of EPO.

When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? - ANSWER-unexplained vaginal bleeding - family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy. 1 / 3

A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? - ANSWER-"I will call your physician to see if we can start some ginger." - This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea.

A client with which of the following conditions is at risk for developing a high ammonia level? - ANSWER-cirrhosis - client with cirrhosis is at risk for developing a high ammonia level.

What is the primary nutritional deficiency of concern for a strict vegetarian? - ANSWER-Vitamin B12 - primary nutritional deficiency of concern for a strict vegetarian.

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A client has been taking alprazolam (Xanax) for 4 years to manage anxiety. The client reports taking 0.5 mg 4 times a day. Which statement indicates that the client understands the nurses teaching about discontinuing the medication? - ANSWER- "I should take 3 pills per day next week, then 2 pills for one week, then 1 pill for one week." - Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia, hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms.

A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to

Vicodin. The nurse should base her reply on the knowledge that: - ANSWER-the

clients body has developed tolerance, requiring more drug to produce the same effect. - drug tolerance is characterized by the ability to ingest a larger dose 2 / 3

without adverse effect and decreased sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and disruption of the persons social, family, and work life. The psychological behaviors related to substance use are termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders.

A safety measure to implement when transferring a client with hemiparesis from a

bed to a wheelchair is: - ANSWER-moving the wheelchair close to clients bed and

standing and pivoting the client on his unaffected extremity to the wheelchair.

A client with dumping syndrome should _____ while a client with GERD should _____. - ANSWER-lie down 1 hour after eating; sit up at least 30 minutes after eating - clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula? - ANSWER-6 liters/minute - Higher flow rates must be delivered by mask.

The kind of man who beats a woman is: - ANSWER-from any walk of life, race,

income group, or profession - batterers cannot be predicted by demographic features related to age, ethnicity, race, religious denomination, education, socioeconomic status, or class. 95% of domestic abuse cases involve male perpetrators and female victims.

Which of the following should be performed when fetal heart monitoring indicates

fetal distress except: - ANSWER-Decreasing maternal fluids - only intervention

that should not be performed when fetal distress is indicated.

What interpersonal relief behavior is Ashley using? - ANSWER-Somatizing - means one experiences an emotional conflict as a physical symptom. Ashley manifests several physical symptoms associated with severe anxiety. Acting out

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