Past Nclex Questions 4

Past Nclex Questions 4 1.A client with sever acute respiratory syndrome privately informs a nurse that he doesn’t want to be placed on a ventilator if his condition worsens. The client’s wife and children have repeatedly expressed their desire that every measure be taken for the client.

The most appropriate action by the nurse would be to:

A.Inform the family of the client’s wishes.a.B.Assure the family that all possible measures will be taken.b.C.Support the client’s decision.c.D.Assure the client that all possible measures will be taken.

2.82.A nurse is caring for a client who is scheduled for a amniocentisis. What information about the procedure should the nurse provide before the client signs the consent form?A.Name of procedure, how it’s performed, description of alternate methods available, potential risk to mother and fetus, risks associated if the procedure isn’t performed.B.Name of procedure, risk to mother, name of physician who will perform procedure C.Name of procedure, risks to the fetus D.Description of alternate methods available, duration of the procedure, day and time the scheduled procedure will be performed.

3.83.A client, who is bound to a wheelchair, comes to the clinic for follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid

dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair he uses a cushion. During his appointment the nurse notes that he isn’t using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse approach the client about his treatment regimen?A.Do nothing because the client is able to make his own care decisions.B.Tell the client not to return to the clinic because he isn’t following the treatment plan.C.Explain pressure ulcer development in terms he understands.D.Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

4.84.The nurse identifies which of the following clients as being at HIGHEST risk for injury?A.A 3-month-old child is in an infant seat that her mother has placed on the coffee table.B.A 2-year-old is playing alone in the living room.C.A 2 1/2-year-old with a tracheostomy is eating raisins.D.A 10-year-old stays home alone for half an hour after school.

5.85.The nurse supervises an LPN/LVN provide care to a patient with an infected abdominal wound. The nurse notes a Penrose drain in place and the wound is draining copious amounts of purulent drainage. The nurse determines care is appropriate if which of the following is observed?

A.The LPN/LVN dons clean gloves, removes the soiled dressing, and puts on a pair of clean gloves to dress the wound.B.The LPN/LVN dons clean gloves, removes the soiled dressing, changes to sterile gloves, and uses sterile dressings to cover the wound.C.The LPN/LVN dons sterile gloves, removes the soiled dressing, changes to clean gloves, and uses sterile dressings to cover the wound.D.The LPN/LVN places the client in protective isolation, removes the old dressings using sterile gloves, and applies sterile dressing using sterile technique.

6.86.The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the

following actions? Select all that apply:

A.Record the dose of medication administered.B.Photocopy the incident report for the nurse’s personal files.C.Perform an assessment of the client.D.Contact the physician.E.Chart any adverse reaction the client experienced.F.Submit the report to the risk manager within 48 hours.

7.87.The nurse returns to a senior center to evaluate the effectiveness of a presentation about how to prevent falls among seniors. The nurse determines that teaching was effective if the seniors state which of the following?

A.“I started taking Tai Chi classes.” B.“I have a new pair of athletic shoes with deep treads.” C.“I went to the eye doctor to have my vision checked.” D.“My physician reviewed all of my medications.” E.“I stopped exercising so I won’t fall.” F.“I bought some new lamps for my home.” 8.88.The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the

following actions? Select all that apply:

A.Record the dose of medication administered.b.B Photocopy the incident report for the nurse’s personal files.c.C. Perform an assessment of the client.d.D. Contact the physician.e.E. Chart any adverse reaction the client experienced.f.F. Submit the report to the risk manager within 48 hours.

9.89.A female college freshman visits the health center because she feels nervous, irritable, and extremely tired. She complains that, although she eats large amounts of food, she has frequent bouts of diarrhea and is losing weight. The nurse observes a fine hand tremor, an exaggerated reaction to external stimuli, and wide- eyed expression. What laboratory tests may be ordered to determine the cause of these signs and symptoms?A.PTT and PT B.T3, T4, and TSH C.VDRL and CBC D.ACTH, ADH and CRF