KAPLAN NCLEX COMPREHENSIVE TEST EXAM

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KAPLAN NCLEX COMPREHENSIVE TEST EXAM The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1. A patient was raped 30 minutes... ago and expresses feelings of self-blame, anxiety, and worthlessness. 2. A patient indicates an intent to kill himself and says he has access to a gun. 3. A patient had a miscarriage last evening and is experiencing anger and resentment. 4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety. Correct Answer: Strategy: "FIRST" indicates priority. 1) need to assess physical needs and examine patient; second patient to see 2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat 3) allow client to verbalize feelings 4) allow client to verbalize feelings The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions? 1. Time the frequency of the contractions. 2. Assess the type of vaginal discharge. 3. Monitor the strength of the contractions. 4. Observe the perineum. Correct Answer: Strategy: Assess before implementing. 1) priority is assessing if baby is crowning 2) priority is assessing if baby is crowning 3) labor is not the priority; nurse should determine if the birth is imminent 4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant's head; apply slight pressure to control delivery The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST? 1. Contact the nursing supervisor. 2. Tell the emergency management team they will have to re-route 25 victims. 3. Activate the hospital's disaster plan. 4. Inform the emergency department nurses they must work overtime. Correct Answer: Strategy: "FIRST" indicates priority. 1) CORRECT— nurse must follow chain of command 2) not the nurse's responsibility 3) must notify immediate supervisor about the call; disaster plans are hospital policies that detail how nurses are to perform duties 4) not the responsibility or role of the nurse As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?" 1. "This medication helps me with my depression." 2. "I will notify my physician if I show signs of hyperactivity and mania." 3. "I will see improvement in my symptoms in 1 to 4 weeks." 4. "If I experience a fever I will take Tylenol." Correct Answer: Strategy: "Further teaching is necessary" indicates incorrect information. 1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat depression 2) side effects: mania, hypomania, insomnia, impotence, headache, and dry mouth 3) true statement 4) correct— should notify physician immediately to assess for serotonin syndrome, which is a rare, life threatening event caused by SSRIs; symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes; may result in death The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with COPD with an PaO 2 of 70%. 2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured. 3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back. Correct Answer: Strategy: "FIRST" indicates priority. 1) oxygenation considered "normal to good" for client with COPD; stable client 2) physical needs take priority 3) requires preop injection; all other preparation should be completed; stable client 4) CORRECT— may indicate hemorrhage from operative site; unstable client The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child? 1. Guacamole with pita bread, lettuce, tomato juice. 2. Poached halibut, brown rice, carrots, peach cobbler. 3. Scrambled eggs, whole wheat toast, nectarine, skim milk. 4. Baked chicken leg, mashed potatoes, spinach, milkshake. Correct Answer: Strategy: "Teaching is effective" indicates correct information. 1) if a person has a latex allergy, there is cross-reaction to tomatoes and avocados 2) peach is a cross-reactive food with latex 3) nectarine are cross-reactive with latex 4) CORRECT— this meal does not have any cross-reactive foods with latex; foods to avoid include apricots, cherries, grapes, kiwis, passion fruit, bananas, avocados, chestnuts, tomatoes, and peaches The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children? 1. A child just returned from a 2-week trip to Europe. 2. A child recently moved to an apartment because the family lost their home. 3. A child with a new nanny who just emigrated from Latin America. 4. A child who weighed 4 lb, 10 oz at birth. Correct Answer: Strategy: All answers are assessments. Determine how they relate to risk factors for tuberculosis. 1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and Caribbean; consider screening if child has traveled to an endemic region 2) the homeless and impoverished are at risk for developing tuberculosis 3) CORRECT— children traveling to endemic areas or who have prolonged, close contact with indigenous persons should undergo immediate skin testing 4) no reasons to undergo immediate screening The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions? 1. Obtain vital signs. 2. Identify the source of the bleeding. 3. Elevate the head of the bed 30°. 4. Administer 0.9% NaCl IV. Correct Answer: Strategy: Assess before implementing. 1) assessment; more important to determine the source of bleeding 2) CORRECT— assessment first step; initial priority to identify and then apply direct pressure and elevate affected area if possible 3) intervention; elevate the extremities 4) intervention; 1-2 liter bolus of isotonic fluids (lactated Ringer or 0.9% NaCl) will be given During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate? 1. "I want to see both of you in my office right away." 2. "Would you please lower your voices and finish the report." 3. "I want the two of you to stop yelling and work this problem out." 4. "Both of you are good nurses and are under a lot of stress right now." Correct Answer: Strategy: Determine the outcome of each response. Is it appropriate? 1) confrontation is not the appropriate conflict management approach when emotions are high 2) CORRECT— forcing is the most appropriate conflict management technique; enables nurses to exchange information; client care takes priority over interpersonal conflict 3). need cooling-off period before issues can be discussed; communicating about patient care takes priority 4) "don't worry" response; may make the nurses feel better but does not address the immediate task of completing the report A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following? 1. Slowed pulse and reduced blood pressure. 2. Constipation and decreased bowel sounds. 3. Palpitations and nervousness. 4. Difficulty voiding and oliguria. Correct Answer: Strategy: "MOST important" indicates discrimination is required to answer the question. 1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine 2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water 3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures 4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes? [Show More]

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