NCLEX-RN EXAM REVIEW

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NCLEX-RN EXAM REVIEW

133 terms Family_firstPreview Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview NCLEX Teacher Tuto The nurse cares 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.
• Thyroid studies.
• Drug toxicology screen.
• Trendelenburg test.

(1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct—test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is 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 oral intake as

long as the tracheotomy is in place.

• Nutritional and/or gastric feedings will not be

attempted for approximately 3 weeks to decrease the incidence of aspiration.

• Because the client is dependent on the ventilator,

nutritional intake will be delayed.(1) correct—tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator

For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client's level of consciousness?

• Client posturing.
• Glasgow coma scale.
• Client thinking pattern.
• Occurrence of hallucinations.

(1) indicates increased intracranial pressure (2) correct—Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates 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.

(1) common with anorexia (2) seen with anorexia (3) correct—due to frequent vomiting (4) bulimics are normal in appearance The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions?

• Evaluate the urine output.
• Obtain the client's weight.
• Determine the patency of the IV line.
• Measure pulmonary artery pressures.

(1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct—if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?

• The nursing assistant answers the phone while wearing

gloves.

• The nursing assistant log rolls the patient to provide

back care.

• The nursing assistant places an incontinent pad under

the patient.

• The nursing assistant positions the patient on the left

side, head elevated.(1) correct—contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following?

• Sore throat, fever, increased fatigue, vomiting, diarrhea.
• Dry mouth, nasal stuffiness, weight gain.
• Rapid heartbeat, frequent headaches, yellowing of

eyes or skin.

• Weakness, staggering gait, tremor, feeling of

drunkenness.(1) correct—possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) not side effects of Tofranil (4) not side effects of Tofranil

The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST?

• A patient post coronary artery bypass graft (CABG)

having the atrioventricular (AV) wires removed later in the day.

• A patient with type 1 diabetes scheduled for a cardiac

catheterization later today.

• A patient 1 day postoperative with an epidural catheter

in place.

• A patient diagnosed with cardiomyopathy being

evaluated for a heart transplant.(1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct —epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority A child has a closed transverse fracture of the 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 child closes her

eyes.

• Apply baby powder to decrease skin irritation under

the cast.(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment; temperature indicates decreased circulation but is subjective and not most important (3) assessment; upper (not lower) extremity fracture (4) implementation; should not be done because it would increase skin irritation The nurse cares for a multipara client who delivered a female infant 1 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.
• Offer the client the bedpan.
• Put the baby to breast.
• Massage the uterine fundus.

(1) encourage the client to void before catheterizing (2) correct—boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?

• A small amount of white mucus is aspirated from the NG

tube.

• The contents aspirated from the NG tube have a pH of

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.(1) mucus may be from lungs (2) correct—stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication

The nurse cares for a client after right cataract surgery.The nurse should intervene if which of the following is observed?

• Client is in the supine position.
• The head of the bed is elevated 30 degrees.
• The client is lying on the right side.
• An eye shield is over the right eye.

(1) appropriate position (2) decreases swelling and pain (3) correct—client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?

• 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.

• Risk for fluid volume excess related to secretions.

(1) constipation is not a problem because the client has diarrhea (2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) may be risk of fluid volume deficit due to diarrhea and secretions The nurse cares for a client one day after a thoracotomy.Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following?

• 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.

(1) correct—primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure The mother of a 7-year-old child is dying. The nurse anticipates the child will 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.

(1) correct-7-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death