NCLEX Question Trainer Explanations

NCLEX Question Trainer Explanations Test 6 Theinurse ireturns itoithe inurse’s istation iafterimaking iclient irounds iand ifinds ifouriphone imessages. iWhich iof ithe ifollowing imessages ishould ithe inurse ireturn iFIRST? Aiclient iwith ihepatitis iAiwho istates,i“Myiarms iand ilegs iare iitching.” Aiclient iwith ia icastionithe iright ileg iwho istates, i“Iihave ia ifunny ifeeling iin imyiright ileg.” Aiclient iwith iosteomyelitis iof ithe ispine iwho istates, i“Iiam isoinauseous ithat iIican’t ieat.” Aiclient iwith iarthritis iwho istates, i“Iiam ihaving itrouble isleeping iat inight.” Strategy: iEliminate ithe imost istable iclients. caused ibyiaccumulation iof ibile isalts iunderitheiskin; itreat iwith icalamine ilotion iand iantihistamines correct—mayiindicate ineurovascularicompromise;irequires iimmediate iassessment requires ifollow-up ibut inot ihighest ipriority requires iassessmentibut inot ithe ihighest ipriority Following ihip ireplacement isurgery, ian ielderly iclient iis iordered ito ibegin iambulation iwith ia iwalker.Whichi iof ithe ifollowing istatements ibyithe inurse iis iBEST? “Sit iin ia ilowichairiforiease iin igetting iup ito iuseithe iwalker.” “Makeisureirubbericaps iareiin iplace ioniall ifourilegs iof ithe iwalker.” “You iwill ibegin iweight-bearing ion ithe iaffected ihip isoon.” “Practice itying iyouriown ishoes ibeforeiyou ibegin iambulating.” Preparation for the Nursing Licensure Examination 38 Strategy: iAll ianswers iareiimplementations. iDetermine ithe ioutcomeiofieach ianswerichoice. iIs iitdesired?i full iweight ibearing ioriflexion iof itheihip igreaterithan i90° ishould ibe iavoided iforifourito isix iweeks correct—intact irubbericaps ishould ibe ipresent ioniwalkerilegs ito iprevent iaccidents full iweight ibearing ioriflexion iof itheihip igreaterithan i90° ishould ibe iavoided iforifourito isix iweeks full iweight ibearing ioriflexion iof itheihip igreaterithan i90° ishould ibe iavoided iforifourito isix iweeks 37 A i22-year-old iwoman icomes ito ithe ihospital iat iterm iin ithe iearly istages iof ilabor. iA idiagnosis iof icomplete iplacenta iprevia iis imade. iItiwould ibe iMOST iimportant iforithe inurse itoitake iwhich iof itheifollowing iactions? Start ian iIViof iterbutaline i(Brethine)iand imonitorithe ipatient’s ivital isigns iclosely. Prepare ithe ipatient iforian iimmediate icesarean isection. Maintain ithe ipatient ion ibedrest iuntil ispontaneous ivaginal idelivery iis iachieved. Monitorithe ipatient’s ilength iand iduration iof icontractions. Strategy: iAnswers iare iboth iassessments iand iimplementations. iIs ithe iassessment iappropriate?No.i iDetermine ithe ioutcomeiof ieach iimplementation. iIs iitidesired? implementation, iBrethine iused ito idelayideliveryiin ipreterm ilabor correct—implementation, icannot ideliverivaginally implementation, icannot ideliverivaginally assessment, icannot ideliverivaginally, icesarean isection imustibeiperformed Which iof ithe ifollowing inursing iobservations iwould iindicate ito ithe inurse ithat ia ichild iwith iepiglottitis iis ihaving ian iearly icomplication iof ihypoxemia? Heart irate iofi148 ibeats iperiminute. Bluish idiscoloration iof ithe iskin. Bluish idiscoloration iaround ithe imouth. Difficultyiswallowing. NCLEX Question Trainer 39 Strategy: iDetermine ihowieach ianswerichoice irelates ito iepiglottitis. correct—heart irate icorrelates iwith ihypoxemia iand iis ian iearlyifinding, ialong iwith irestlessness cyanosis, ilate isign circumoral icyanosis, ilate isign sign iof iepiglottitis After istabilizing ia iclient iwith isevere imultiple itrauma iinjuries ifrom ia imotor ivehicle iaccident, iwhich iof ithe ifollowing iactions ibyithe inurse iis iBEST? Limit ivisiting ihours itoipromote ioptimal irest. Arrange iforiclergyito ivisit iwith ithe iclient iand ifamily ias irequested. Arrange iforia ipsychologist ito ivisit iwith ithe ifamily. Arrange iforithe ifamilyito imeet iwith ia isocial iworkerito idiscuss ifinancial iaid. Strategy: iAll ianswers iareiimplementations. iDetermine ithe ioutcomeiofieach ianswer. iIs iitidesired? inappropriate correct—would iprovide ithe iappropriate ispiritual isupport inecessaryiduring ia icrisis inappropriate iforithe idata igiven iin ithe isituation inappropriate iforithe idata igiven iin ithe isituation The inurse’s iaide icomes ito itake ia iwoman iby iwheelchair iforia imagnetic iresonance iimaging i(MRI)scani iof ithe ihead iand ineck.iWhich iof ithe ifollowing iobservations, iif imade iby ithe inurse, iwould irequire ian iintervention? Theiwoman iremoves iheridentures iand igives ithem ito iherihusband. Theiwoman’s ivital isigns iare: iBPi120/70, ipulse i80, irespirations i12, itemperature i99°Fi(37.3°C). Theiwoman ihas iainitroglycerine ipatch ion iheriright ichest iarea. Theiwoman ihas iredinail ipolish ion iherifingers iand itoes. Strategy: i“Require ian iintervention”iindicates ian iincorrect iaction. should ibe iremoved ibeforeithe itest results iare iwithin inormal ilimits