Nclex Comprehensive Exam 1

NCLEX COMPREHENSIVE EXAM 1 EXAM QUESTIONS , CORRECT VERIFIED ANSWERS AND RATIONALE 100% PASS A nurse is reviewing the health care provider's (HCP's) admitting prescriptions for a post-menopausal woman scheduled for a dilatation and curettage. The nurse is unable to decipher the handwriting but thinks the medication prescription reads either metoprolol or topiramate. What should the nurse do next? -Ask the client if she has hypertension. -Ask the client if she has migraines. -Call the HCP to clarify the prescription. -Ask the pharmacist to interpret the prescription. Answer Call the HCP to clarify the prescription. Rational: The nurse must clarify this prescription with the admitting HCP to ensure medication accuracy and client safety. In health care settings without computerized medical records or computer prescribing, misinterpretation of handwriting remains a leading cause of medication errors. It is not safe practice to question the client regarding a diagnosis and assume the medication is correctly prescribed. The pharmacist will need clarification of the prescription as well. It is not the role of the pharmacist to interpret the prescription. A physician orders meperidine 30 mg I.M. as preoperative medication for a school-age child who weighs 66 lb (30 kg). The meperidine is supplied as 50 mg/mL. How much meperidine should the nurse administer? - 0.3 mL - 0.5 mL - 0.6 mL - 0.8 mL Answer 0.6 mL A client with acute asthma is experiencing inspiratory and expiratory wheezing, and decreased forced expiratory volume. What is the nurse's priority intervention? - Beta-adrenergic blockers - Bronchodilators - Inhaled steroids - Oral steroids Answer Bronchodilators Rational: Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma, and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce inflammation but aren't used for emergency relief. A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: - check the client frequently at irregular intervals. - assure the client that the nurse will hold in confidence anything the client says. - repeatedly discuss the client's previous suicide attempts. - disregard decreased communication by the client because decreased communication is typical of suicidal clients. Answer check the client frequently at irregular intervals. Rational: Checking the client frequently but at irregular intervals prevents the client from anticipating when observation will take place and altering behavior in a misleading way at these times. Assuring the client that information will be held in confidence may encourage the client to try to manipulate the nurse or seek attention by claiming a secret suicide plan. Repeatedly discussing previous suicide attempts may reinforce the client's suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it. The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply. -Make frequent changes in the client's routine. -Engage the client in complex discussions to help improve memory. -Furnish the client's environment with familiar possessions. -Assist the client with activities of daily living (ADLs) as necessary. -Assign tasks in simple steps. Answer -Furnish the client's environment with familiar possessions. -Assist the client with activities of daily living (ADLs) as necessary. -Assign tasks in simple steps. Rational: A client with Alzheimer's disease experiences progressive deterioration in cognitive functioning. Familiar possessions may help to orient the client. The client should be encouraged to perform ADLs as much as possible but may need assistance with certain activities. Using a step-by-step approach helps the client complete tasks independently. A client with Alzheimer's disease functions best with consistent routines. Complex discussions do not improve the memory of a client with Alzheimer's disease. A client is receiving chemotherapy and tells the nurse about also taking herbal therapy. What should the nurse do next? - Determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using. - Guide the client in the decision-making process to select either Western or alternative medicine. - Encourage the client to seek alternative modalities that do not require the ingestion of substances. - Recommend that the client stop using the alternative medicines immediately. Answer Determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using. Rational: The role of the nurse is to assess what substances or medications the client is using and to document and inform other members of the health care team. It is very important to encourage the client to keep the HCP informed of all therapeutic agents, medications, and supplements she is using, to avoid adverse interactions. It is not appropriate for the nurse to suggest that the client choose either Western or alternative therapies or to discourage the client's use of alternative therapies. The nurse should remain objective about the client's treatment choices and respect her autonomy. When assessing a client with asthma, which findings would most likely indicate the presence of a respiratory infection? - cough productive of yellow sputum - bilateral expiratory wheezing - chest tightness - respiratory rate of 30 breaths/min Answer cough productive of yellow sputum Rational: A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present. A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? -a palpable radial pulse -a palpable ulnar pulse -cool, pale fingers -pink nail beds Answer cool, pale fingers Rational: A wrist-safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings. A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent? - "All visitors should wash their hands before they leave or enter the room." - "Cover your mouth and nose when you cough or sneeze in the room." - "Do not bring fresh flowers or fruit to the room after surgery." - "Wear an isolation gown when entering the room." Answer "All visitors should wash their hands before they leave or enter the room." Rational: Hand washing upon entry and when leaving the client's room should be stressed to visitors to prevent the spread of disease. During the postoperative period, visitors could inadvertently bring in infectious agents to the client. Telling the family to cover their mouths and noses when coughing and sneezing does not decrease postoperative infection risks as much as hand washing would impact the client. Fresh flowers and fruit are restricted for neutropenia clients. Isolation gowns would not be necessary in a noninfected postoperative client. A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? - Institute droplet precautions. - Obtain the child's vital signs. - Ask the parent about medication allergies. - Inquire about the health of siblings at home. Answer Institute droplet precautions. Rational: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed. When a client is placed in balanced skeletal traction, the nurse should: - ensure that the traction weights hang freely from the bed at all times. - increase the traction weight gradually as the client's tolerance increases. - apply and remove the traction weights at regular intervals throughout the day. - remove the weights briefly as necessary to reposition the client in bed. Answer ensure that the traction weights hang freely from the bed at all times. Rational: In balanced skeletal traction, the appropriate pressures and counter pressures are applied to the fracture site, with the traction weights hanging freely at all times.The amount of traction weight used is determined by radiography and the alignment of the fracture.These weights are in place continuously and should never be lifted, reduced, or eliminated. Which intervention is an example of primary prevention? - administering digoxin to a client with heart failure - administering a measles, mumps, and rubella immunization to an infant - obtaining a Papanicolaou (Pap) test to screen for cervical cancer - using occupational therapy to help a client cope with arthritis Answer administering a measles, mumps, and rubella immunization to an infant Rational: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring. A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type