NCLEX Question Trainer Explanations Test 5

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NCLEX Question Trainer Explanations Test 5 1. The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST im... portant for the nurse to ask? 2. A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective? 3. The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning? 4. A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST? 1. The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST? 2. The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST? 3. The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program? 8. The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse? 9. While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority? 10. A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements? 11. The nurse in a long-term care facility is reviewing the nurse’s notes in a client’s chart. The nurse would be MOST concerned by which of the following entries? 12. The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST? 13. A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST? 14. The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to 15. The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should 16. A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction? 17. The nurse is caring for a client with Cushing’s syndrome. Which of the following nursing actions would be of HIGHEST priority? 18. The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis? 19. The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements? 1 20. A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST? 21. Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella? 1. 22. A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST? 23. The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus? 24. The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure? 25. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client? 26. The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he “felt something give.” The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient 1 27. On a home health visit, an elderly client states, “This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.” Which of the following nursing responses by the nurse is BEST? 28. An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP? 29. The nurse cares for an 8 lb, 8 oz newborn boy. The infant’s history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed? 30. The nurse is assisting a 58-year-old woman from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions? 31. At approximately 6 PM, the nurse begins to open the nurses’ notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to 32. A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client’s therapy if which of the following occurs? 1. 33. Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter? 34. A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching? 1 35. A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following? ....................................................................CONTINUED............................................................. [Show More]

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