NSG 500 NCLEX Test 4 with Explanations- Rush University

NSG 500 NCLEX Test 4 with Explanations- Rush University 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? ← “Promethazine (Phenergan) 25 mg IM 3 h.” ← “Morphine sulfate 10 mg IM q3-4h.” ← “Docusate sodium (Colace) 50 mg PO bid.” ← “Ranitidine (Zantac) 50 mg IVPB q12h.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? ← H1 receptor blocker, used as an antiemetic ← correct–narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure ← stool softener, used for an immobilized patient ← H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers ← 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? ← A woman in her first trimester of pregnancy complaining of heartburn. ← A man complaining of heartburn that radiates to his jaw. ← A woman complaining of hot flashes and difficulty sleeping. ← A boy complaining of knee pain after playing basketball. Strategy: Determine the least stable client. ← caused by reflux of gastric contents into esophagus, treatment is small frequent meals, don’t consume fluids with food, don’t wear tight clothing ← correct–indicates chest pain, needs to seek medical attention immediately ← caused by menopause, treat with hormone replacement therapy (HRT) ← should treat with rest and ice Nursing.................................................................................................................................................................25 P R E P A R A T I O N F O R T H E N U R S I N G L I C E N S U R E E X A M I N A T I O N ................................................ ← 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? ← Head of bed elevated 30°–45°. ← Head of bed elevated 60°–90°. ← Side-lying with head elevated 15°. ← Lying flat with head turned to the left side. Strategy: Remember the positioning strategy. ← not the best position ← correct–facilitates swallowing and movement of tube through GI tract ← not the best position ← not the best position ← The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery. Which of the following symptoms would suggest to the nurse that the patient has fluid volume overload? ← Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. ← Cool skin, respiratory crackles, pulse 86 and bounding. ← Complaints of a headache, abdominal pain, and lethargy. ← Urinary output 700 cc/24 h, CVP of 5, and nystagmus. Strategy: Determine how each answer choice relates to fluid volume overload. ← indicates dehydration ← correct–will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement ← symptoms could be from causes other than volume overload ← slightly reduced output, CVP would be elevated, normal CVP 4-10 mm/H2 O, involuntary eye movements not seen ← A woman has been recently diagnosed with systemic lupus and shares with the nurse, “I am thinking about getting pregnant, but I don’t know how I will be able to tolerate a pregnancy since I have lupus.” Which of the following responses by the nurse is BEST? ← “Most women find that they feel better when they are pregnant.” ← “How long have you been in remission?” ← “Women with lupus frequently have slightly longer gestations.” ← “It is best to become pregnant within the first six months of diagnosis.” Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. ← maternal morbidity and mortality are increased with SLE ← correct–should be in remission for at least 5 months prior to conceiving ← gestation not affected by SLE ← recommended that a woman wait two years following diagnosis before conceiving . . . . . . . . . . ..