Comprehensive NCLEX-RN Latest Test Bank. 2021. All Correct Answers and Explanations. Download for Grade A+
A violent client remains in restraints for several hours. Which of the following interventions is most appropri
...
Comprehensive NCLEX-RN Latest Test Bank. 2021. All Correct Answers and Explanations. Download for Grade A+
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructions to the mother and/or child?
A. Administer oral griseofulvin on an empty stomach for best results.
B. Discontinue drug therapy if food tastes funny.
C. May discontinue medication when the child experiences symptomatic relief.
D. Observe for headaches, dizziness, and anorexia.
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
A. Prevent systemic infection
B. Promote diuresis
C. Decrease ammonia formation
D. Acidify the small bowel
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures
should be included in the postoperative care?
A. Encourage the child to cough up blood if present.
B. Give warm clear liquids when fully alert.
C. Have child gargle and do toothbrushing to remove old blood.
D. Observe for evidence of bleeding.
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:
A. Both lower extremities warm to touch with 2_pedal pulses
B. Both lower extremities cyanotic when placed in a dependent position
C. Decreased or absent pedal pulse in the left leg
D. The left leg warmer to touch than the right leg
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
A. pH 7.39
B. White blood cell (WBC) count 10,000 WBCs/mm3
C. Hematocrit 60%
D. Bleeding time of 4 minutes
A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing intervention is appropriate when communicating with the pacing client?
A. Ask him to sit down. Speak slowly and use short, simple sentences.
B. Help him to recognize his anxiety.
C. Walk with him as he paces.
D. Increase the level of his supervision.
Answer: C
NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to:
A. Evaluate fetal lung maturity
B. Evaluate the amount of amniotic fluid
C. Locate the position of the placenta and fetus
D. Ensure that the fetus is mature enough to perform the amniocentesis
Answer: C
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classified as having:
A. Insulin-dependent diabetes
B. Type II diabetes mellitus
C. Type I diabetes mellitus
D. Gestational diabetes mellitus
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