Nursing 111 Test 2 NCLEX practice questions

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NUR 111

20 terms ama A client who is NPO prior to surgery reports feeling thirsty, what is the physiological process that drives the thirst factor?decreased blood volume and intracellular dehydration a client with diabetes has impaired sensation in her lower extremities what education would be necessary to reduce her risk of injury?Always test the temperature of the bath water before stepping in Which body fluid is the fluid inside the cells, constituting about 70% of total body water?Intracellular fluid (ICF) By what route do oxygen and carbon dioxide exchange in the lungs?Diffusion A nurse responds to the call bell and finds another nurse evacuating the client from their room which has caught fire. Which action should the nurse take?Pull the fire alarm a nurse visits an older adult client at home and assesses the safety of the home environment. what could be a threat to the clients safety?area rugs kept on the stairs without carpet a nurse is preparing discharge education for a new mom what is the priority item that mist be included in the education plan?restrain the baby in a car seat

a nurse assigned to care for a client with a terminal cardiovascular illness is developing an educational care plan. which outcome would the nurse identify as the most realistic for the client to achieve?maintenance of adequate comfort True or false, an ECG uses 10 electrodes/leads to assess the hearts electrical activity from 12 different views True When describing the normal cardiac cycle, which of the following would a nursing instructor describe as occurring during systole?Ventricles eject blood A nurse is working at a local clinic that provides care for families with young children. For a child of which age would the nurse be sure to obtain a blood pressure?

• 2.5yr old
• 2 month old
• 1.5 yr old
• 3.5 yr old

3.5 year old Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall.Which measure does not comply with a least restraint policy?Raising all side rails while the client is in bed A nurse is reading a journal article about cardiovascular disease. What would the nurse most likely find as the most common reason a person seeks medical care?Chest pain A client is scheduled for orthopedic surgery and is prescribed anticoagulant prophylaxis. Which agent would the nurse most likely expect to administer if prescribed?Low molecular weight heparin A client with angina is prescribed sublingual nitroglycerin.After teaching the client about this medication, the nurse determines that additional education is needed when the

client states:

I can store the medicine on my counter in a clear glass container The nurse is working at a local elementary school. A mother arrives to pick up her 6-year-old son and has her 2-year-old daughter in tow. Based on the nurse's developmental knowledge of toddlers, which behavior would most concern the nurse?The two year old leaning against the screen of a window in a classroom A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?placing the tourniquet on the upper arm for 2 minutes A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

A child age 5 years wakes up at night and finds he has wet the bed. He feels embarrassed that he had this accident and sleeps in the wet bed all night, afraid to tell his parents. In the morning, he wakes up early, gets dressed, and hides his pajamas because he still feels shame for this accident. This child is experiencing which feeling of self-evaluation?Shame The nurse is assisting an adolescent female with the identification and recognition of personal strengths.Which of the following is a technique the nurse will employ?Encourage the client to identify strengths and ways to gain strengths she desires A nurse finds a client in his room asphyxiated with carbon monoxide inhalation. which activity would be the priority for the nurse?get the victim out of the present environment a client loses consciousness after strenuous exercise and needs to be admitted for dehydrations. What needs to be restored?electrolytes A patient with renal failure is found to have an elevated potassium of 6.0mEg/L. the effect of the high potassium is a problem with conduction resulting in abnormal cardiac rhythm. which of the following describes this type of abnormality?

• mitral regurgitation
• MI
• low CO
• Dysrhythmia
• Dysrhythmia

a 65 year old male is seen in an internal medicine clinic for an annual exam. which of his conditions or risk factors increased his risk for atherosclerosis?

• hypertension
• hyperlipidemia
• cigarette smoking
• depression

hypertension, hyperlipidemia and cigarette smoking the pt. described above was told to modify his lifestyle to decrease his risk for atherosclerosis. which would be the most important modification to emphasize?

• quit smoking
• take a anticoagulant
• reduce salt intake
• decrease fluid consumption

quit smoking

a nurse find the following signs on assessment of a

patient: 3+ ankle edema, feet cool to touch, HR 116, JVD.

which diagnosis best fits these findings

• endocarditis
• right sided heart failure
• atrial fibrillation
• postoperative fluid overload

right sided heart failure a patient admited with coronary artery disease as a result of diabetes mellitus type 2 is best classified using what nursing diagnosis?

• risk for decreased cardiac output
• self-care deficit
• activity intolerance
• infection

risk for decreased cardiac output a new mom has a BP of 70/49 and GR of 126 immediately postpartum which nursing Dx is highest priority?

• ineffective tissue profusion
• activity intolerance
• risk for infection
• ineffective childbearing process

ineffective tissue profusion which of the following outcomes is highest priority for an end stage renal disease pt. on hemodialysis at risk for fluid overload? select all that apply

• knowledge of treatment regimen

b. respiratory status: ventilation

• urinary continence
• electrolyte balance

A &D a nurse is assessing the feet of a Pt on bedrest wearing antiembolism stockings. she finds edema with deep creases from the stockings and the toes cold to the touch. what is the best nursing intervention?

• apply SCDs
• remove the antiembolism stockings
• perform calf pumping exercises
• call the physician for anticoagulation medications
• remove the stockings because they should be taken off every 8hrs. toes should

remain warm and no obvious constriction should be noted a Pt. with a history of anxiety reports pain in her chest which response by the nurse is most appropriate?

• let me see if I can give you your pain meds yet
• try to relax, ill dim the lights and give you a back rub
• when did the pain start and what were you doing when

it started?

• i will call a code, this an emergency
• when did the pain start and what where you doing when it started