LATEST NCLEX practice Q&A WITH RATIONALES

LATEST NCLEX practice Q&A WITH RATIONALES A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence? Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance. - ANSWER-C RATIONALE-Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client. A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? Client with shock Client with anemia Client with epilepsy Client with peripheral vascular disease - ANSWER-C RATIONALE-A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes. While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? Anemia Pregnancy Lung disease Autoimmune disease - ANSWER-D RATIONALE-Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tanbrown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiplechoice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place. - ANSWER-42.8 RATIONALE-Fahrenheit is converted to Celsius by subtracting 32 from the Fahrenheit reading and multiplying the obtained value by 5/9. C = (F - 32)(5/9) C = (109 - 32)(5/9) C = 42.8 The nurse is caring for a client who is on a lowcarbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine? Protein Glucose Ketones Uric acid - ANSWER-C RATIONALE-As a result of fat metabolism, ketone bodies are formed, and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low-carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? Promote equalization of osmotic pressures Prevent hypoxia associated with diaphoresis Promote integrity of intracerebral neurons Reduce brain metabolism and limit hypoxia - ANSWER-D RATIONALE-Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs. Which question asked by the nurse is an example of open-ended questions? "How has your health been?" "Are you feeling any pain now?" "Do you think the medication is helping you?" "How would you rate your pain on a scale from 0 to 10?" - ANSWER-A What is an example of third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation - ANSWER-A