NUR 1213 Module 4 NCLEX Questions & Answers Complete with Answers
NUR 1213 Module 4 NCLEX Questions & Answers
•	A primigravid client at 26 weeks’ gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?
RATIONALE: Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. To avoid heartburn during pregnancy, the client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of pregnancy. Displacement of the stomach by the uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of hydrochloric acid also contributes to heartburn during pregnancy.
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, “How could God do this to me? I’ve never done anything wrong.” Which of the following responses by the nurse would be most appropriate at this time?
RATIONALE: Acknowledging the anger and its source encourages communication about the client’s feelings. Although anger at God is common after a loss, the client is displacing the anger that she needs to deal with more directly. Telling the client that the miscarriage was an accident or that she is a strong person and will get through this ignores the client’s feelings of anger and loss, thereby cutting off communication.
A client with cancer has been advised by the physician that he should have chemotherapy. The client is concerned about chemotherapy and wants to take herbal treatments instead. The nurse’s best response to the client is which of the following?
RATIONALE: Asking the client to speak about his concerns encourages open discussion. Telling the client that he is making a mistake is judgmental of the client’s wishes and eliminates opportunities for the client to explore the situation and discuss various treatment options. Saying that herbal treatments have not been approved by the FDA or that they have not been researched is irrelevant, places a value judgment on the client’s wishes, and provides no opportunity for discussion.
A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization?
RATIONALE: The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.
A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
RATIONALE: Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
RATIONALE: Asking the mother to talk about her concerns acknowledges the mother’s rights and encourages open discussion. The other responses negate the parent’s concerns.
A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply.
RATIONALE: The breast-feeding mother is encouraged to avoid potentially allergic foods, such as fish and peanuts, during the first several months.
A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is:
RATIONALE: The Meals on Wheels program delivers meals to clients once a day in their homes. In addition to the improved nutrition, it is commonly valued as a means to check on elderly persons who live alone. Hospice care involves daily needs for the terminally ill at home. VNA provides skilled nursing care to clients at home. AARP is a national organization for retired people, not a health care organization.
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
RATIONALE: The cardiovascular status of the client is the first information documented, and will validate the effectiveness of the temporary pacemaker. The client’s emotional state and the type of sedation are important but not a high priority. The nurse will need to document the pacemaker information (settings of the pacemaker); this will be considered part of the cardiovascular information.
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
RATIONALE: Using a special feeding table or modified high chair is the best method for an infant who is used to sitting up for feedings. The child should not be flat because of the danger of aspiration. Raising the child’s head will not work as well as using a feeding table because the child is not used to lying down to eat. Two people are not necessary.
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
RATIONALE: The National Association for Home Care (NAHC) defines “home care” as services for people who are recovering, disabled, or chronically ill and who are in need of treatment or support to function effectively in the home environment. The client with multiple sclerosis and an open lesion is at risk for infection and will require assistance with managing the lesion. Prothrombin monitoring is usually done at the clinic or health care provider office. Diet instruction can be accomplished at a health care facility or dietitian office. The client with vertigo should be monitored for safety in the home. Clients receiving home care services are usually under the care of a physician with the focus of care being treatment or rehabilitation. Lenses for glasses can be evaluated at an eye clinic or an ophthalmologist’s office; a prescription for stronger lenses could be written.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below (see figure). The nurse identifies this rhythm as:
RATIONALE: Ventricular tachycardia is recognized by a wide QRS complex; the rhythm may be regular or irregular. The P waves, if observed, are not related to the QRS complex. Ventricular tachycardia is a major arrhythmia and must be treated immediately.
The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?
RATIONALE: Although coordinating documentation, resolving negative feelings, and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.
The nurse is caring for a client who has experienced severe multiple trauma. The client’s arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. The nurse is aware that this finding is a major indicator of the development of which of the following conditions?
RATIONALE: ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client’s chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.
A client asks the nurse why he was asked to complete an advance directive when he entered the hospital. The nurse’s best response is which of the following?
RATIONALE: By federal law, all clients entering a hospital or hospice program are offered the chance to make an advance directive, so that their wishes will be known and followed in an emergency. The directive is not a substitute for informed discussion with the physician. Worry about extraordinary means being taken can be discussed with the client later, but the client needs to be informed that the directive is a federal requirement to protect the client’s autonomy.
When witnessing an adult client’s signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
RATIONALE: The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.
A pregnant woman at 22 weeks’ gestation is diagnosed with gonorrhea. The physician orders doxycycline (Vibramycin). The nurse should first:
RATIONALE: Doxycycline is contraindicated in pregnancy because it can stain the teeth of the developing fetus when given during the last half of pregnancy. The nurse should withhold the drug and notify the physician to change the order. All neonates are given prophylactic ophthalmic ointment for the prevention of ophthalmic neonatorum, conjunctivitis caused by gonorrhea. Naprosyn and aspirin may be used to treat headaches. Imuran is used to prevent rejection of transplanted organs.
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
RATIONALE: The contraction stress test simulates labor and determines the fetal response to the labor process and the mother’s contractions. Therefore, determining that contractions have ceased after the test is important. Although spontaneous rupture of membranes is a possibility after a contraction stress test, it is not a typical occurrence. The test should not affect the viability of the fetus. Fetal viability is related to gestational age. A fetus of at least 23 weeks’ gestation is considered viable, or capable of extrauterine life. A negative contraction stress test should not affect or alter fetal heart rate variability.
An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
RATIONALE: A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status.
A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse’s best response is which of the following?
RATIONALE: Salmeterol (Serevent) is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol (Proventil) is used as the “rescue inhaler” for bronchospasms. Serevent can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking Serevent twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for Serevent include only asthma and bronchospasm induced by chronic obstructive pulmonary disease.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
RATIONALE: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, edema, and hyperlipidemia and normal or lower than normal blood pressure. Elevated streptococcal antibody titers are associated with poststreptococcal glomerulonephritis, an immune complex disease.
A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance?
RATIONALE: Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.