Kaplan NCLEX-RN Question
Trainer #1 | 50 Comprehensive
Nursing Questions and
Rationales
The nurse provides care for a client who returns to the unit after a new gastrostomy
tube is placed. The nurse undserstands which is expected? SATA - answer-2.) reports
of surgical site discomfort (soreness is expected for several days after placement)
4. flush tube with water b4 and after all meds
5.) admin the tube feeding at room temp (to prevent cramping and promo digestion)
- elevate hob for 1 hr after feeding to prevent aspiration
-provide skin care around tube
-complications (aspiration, diarrhea, abd distention, hyperglycemia, impaction)
- enteral feedings can be started within a few hrs of gastrostomy tube placement if
prescribed
the nurse recieves a message on social media from a former client. The message
reads, "I thought you were so nice and would like to be friends." Which action by the
nurse is appropriate? - answer-IGNORE the message and delete it ( in order to prevent
any additional communication, the nurse should ignore and delete the message)
A client is admitted to the behavioral health unit with a labile mood, laughing loudly, then
curing at the staff. The client paces up and down the hallway talking about a myriad of
subjected to anyone who will listen. Which disorder does the nurse recall with these
attributes? - answer-BIPOLAR disorder
-bipolar disorder includes attributes of elevated behavior when in the manic state
include labile mood, excessive energy, accelerated speech, thought, and movement.
They talk non-stop to anyone who will listen , oten in loud tnes and may be difficult to
redirect while in manic state. The other attribure of bipolar disorder is depression. the
client cycle between mania and depression over hours, days, weeks,and months.
Bipolar disorder treatment (mania and depression) - answer-treatment:
-lithium
- paritcular anticonvulsant medications: (carbamazepine, valproate, lamotrigine)
- psychotherapy
-antidepressants
, The nurse observes a client with anxiety having increased wringing of hands and
purposeless pacing. Which intervention will the nurse initiate to support the client? -
answer-Walk with the client WITHOUT conversation
(allows the client to perform activities that may help alleviate anxiety symptoms)
the nurse provides care for a client just returned from an MRI of the brain. The client
asks the nurse, "will you tell me the results? do I have cancer?" which response by the
nurse is both therapeutic and appropriate to maintain the legal scope of practice? -
answer-" I am unable to go over the results of the MRI with u, but I will call your health
care provider to come speak with you right away"
the nurse cares for a cient admitted with cerebral vascular accident (CVA) and facial
paralysis. Nursing care is planned to prevent which complication? - answer-Corneal
abrasion
-nursing care cannot prevent inabillity to talk, loss of gag reflex, or inability to open the
affected eye,
- we can prevent corneal abrasion with COOL COMPRESS AND PRESCRIBED EYE
DROPS
- the client cant blink the ey and no longer supply secretions to protect the eye and lead
to corneal abrasions
The nurse completes care for a client on airborne precautions. In which order does the
nurse remove the PPE? - answer-1. remove contaminated gloves by grabbing the palm
of one hand and removing the 1st glove
2. hold contaminated glove in gloved hand and slide it off so that one glove is inside the
other
3.)discard gloves
4.)unfasten the gown ties and make sure the sleeves do note tough the clothing
underneath
5.)pull gown away and touch the inside of the gown only
6.) role gown away from body
7.) discard gown
8.) remove respirator once outside the clients room
9.) discard the respirator
10.) wash hands
* Gloves, Gown, Respirator, Wash hands
Airborne infection precautions - answer-- private room with monitored negative air
pressure with 6 to 12 air changes per hour
-examples of diseases: (measles/rubeola, m. tuberculosis, varicella, disseminated
zoster/shingles)
Trainer #1 | 50 Comprehensive
Nursing Questions and
Rationales
The nurse provides care for a client who returns to the unit after a new gastrostomy
tube is placed. The nurse undserstands which is expected? SATA - answer-2.) reports
of surgical site discomfort (soreness is expected for several days after placement)
4. flush tube with water b4 and after all meds
5.) admin the tube feeding at room temp (to prevent cramping and promo digestion)
- elevate hob for 1 hr after feeding to prevent aspiration
-provide skin care around tube
-complications (aspiration, diarrhea, abd distention, hyperglycemia, impaction)
- enteral feedings can be started within a few hrs of gastrostomy tube placement if
prescribed
the nurse recieves a message on social media from a former client. The message
reads, "I thought you were so nice and would like to be friends." Which action by the
nurse is appropriate? - answer-IGNORE the message and delete it ( in order to prevent
any additional communication, the nurse should ignore and delete the message)
A client is admitted to the behavioral health unit with a labile mood, laughing loudly, then
curing at the staff. The client paces up and down the hallway talking about a myriad of
subjected to anyone who will listen. Which disorder does the nurse recall with these
attributes? - answer-BIPOLAR disorder
-bipolar disorder includes attributes of elevated behavior when in the manic state
include labile mood, excessive energy, accelerated speech, thought, and movement.
They talk non-stop to anyone who will listen , oten in loud tnes and may be difficult to
redirect while in manic state. The other attribure of bipolar disorder is depression. the
client cycle between mania and depression over hours, days, weeks,and months.
Bipolar disorder treatment (mania and depression) - answer-treatment:
-lithium
- paritcular anticonvulsant medications: (carbamazepine, valproate, lamotrigine)
- psychotherapy
-antidepressants
, The nurse observes a client with anxiety having increased wringing of hands and
purposeless pacing. Which intervention will the nurse initiate to support the client? -
answer-Walk with the client WITHOUT conversation
(allows the client to perform activities that may help alleviate anxiety symptoms)
the nurse provides care for a client just returned from an MRI of the brain. The client
asks the nurse, "will you tell me the results? do I have cancer?" which response by the
nurse is both therapeutic and appropriate to maintain the legal scope of practice? -
answer-" I am unable to go over the results of the MRI with u, but I will call your health
care provider to come speak with you right away"
the nurse cares for a cient admitted with cerebral vascular accident (CVA) and facial
paralysis. Nursing care is planned to prevent which complication? - answer-Corneal
abrasion
-nursing care cannot prevent inabillity to talk, loss of gag reflex, or inability to open the
affected eye,
- we can prevent corneal abrasion with COOL COMPRESS AND PRESCRIBED EYE
DROPS
- the client cant blink the ey and no longer supply secretions to protect the eye and lead
to corneal abrasions
The nurse completes care for a client on airborne precautions. In which order does the
nurse remove the PPE? - answer-1. remove contaminated gloves by grabbing the palm
of one hand and removing the 1st glove
2. hold contaminated glove in gloved hand and slide it off so that one glove is inside the
other
3.)discard gloves
4.)unfasten the gown ties and make sure the sleeves do note tough the clothing
underneath
5.)pull gown away and touch the inside of the gown only
6.) role gown away from body
7.) discard gown
8.) remove respirator once outside the clients room
9.) discard the respirator
10.) wash hands
* Gloves, Gown, Respirator, Wash hands
Airborne infection precautions - answer-- private room with monitored negative air
pressure with 6 to 12 air changes per hour
-examples of diseases: (measles/rubeola, m. tuberculosis, varicella, disseminated
zoster/shingles)
