NCLEX 150 QUESTIONS ANSWERS AND CLINICAL REASONING

NCLEX 150 QUESTIONS ANSWERS AND CLINICAL REASONING EXAM PREP # 4 1. A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although ...

NCLEX 150 QUESTIONS ANSWERS AND CLINICAL REASONING EXAM PREP # 4 1. A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although the client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders? 1. “Promethazine (Phenergan) 25 mg IM 3 h.” 2. “Morphine sulfate 10 mg IM q3-4h.” 3. “Docusate sodium (Colace) 50 mg PO bid.” 4. “Ranitidine (Zantac) 50 mg IVPB q12h.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) H1 receptor blocker, used as an antiemetic (2) correct–narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers 2. The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in her first trimester of pregnancy complaining of heartburn. 2. A man complaining of heartburn that radiates to his jaw. 3. A woman complaining of hot flashes and difficulty sleeping. 4. A boy complaining of knee pain after playing basketball. Strategy: Determine the least stable client. (1) caused by reflux of gastric contents into esophagus, treatment is small frequent meals, don’t consume fluids with food, don’t wear tight clothing (2) correct–indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice 3. A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure? 1. Head of bed elevated 30°–45°. 2. Head of bed elevated 60°–90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side.