N1 Final Exam Review Test Bank

N1 Final Exam Review Test Bank...........A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient's condition, questions its appropriateness, and examines alternative treatments. This nurse would most likely Correct Answer: A. call the physician, explain rationale, and suggest a different medication. Response Feedback : Determining how best to proceed on behalf of a patient's best health care outcomes may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient's health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.Cognitive level: applicationNCLEX Blueprint: Management of care • Question 4 0 out of 1 points A nurse is caring for a client with stress incontinence. The nurse knows that which effect could have led to such a condition? Correct Answer: D. Loss of muscle tone Response Feedback : The nurse should know that the loss of muscle tone leads to stress incontinence in the elderly. The bladder muscles become weak, which also leads to urinary retention and dribbling as stress incontinence. Reduced bladder capacity, decreased urine formation, and reduced renal blood flow are common problems associated with the urinary system as a result of advanced age, but they do not specifically lead to stress incontinence.Cognitive Level: ApplicationNCLEX Blueprint: Management of Care • Question 5 1 out of 1 points A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the nurse’s best response? Correct A. Answer: “The surgery will relieve the symptoms but will not cure your father.” Response Feedback: The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.Cognitive level: comprehensionNCLEX Blueprint: Basic care and comfort • Question 6 1 out of 1 points The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is Correct Answer: B. low birth weight. Response Feedback : Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well- nourished infant is not at significant risk.Cognitive Level: applicationNCLEX Blueprint: Physiological Adaptation • Question 7 1 out of 1 points The priority nursing intervention for a patient suspected to be hypothermic would be to Correct D. Answer: remove wet clothes. Response Feedback : The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.Cognitive Level: applicationNCLEX Blueprint: Physiological Adaptation • Question 8 0 out of 1 points The pediatric clinic nurse has just administered a dose of Haemophilus influenzae type B (Hib) vaccine to a child. The nurse explains to the parents that they can expect which type of local reaction following the injection? Correct Answer: B. Pain or redness at site Response Feedback : The parents should be taught to expect pain and redness at the site as possible local reactions to the Hib vaccine. Fever, irritability, and decreased appetite are common side effects of the heptavalent pneumococcal conjugate vaccine (PCV). Cognitive Level: ApplicationNCLEX Blueprint: Health Promotion and Maintenance • Question 9 1 out of 1 points A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? Correct Answer: B. The client’s current weight-bearing status Response Feedback: This is the most important information the nurse needs to know to identify the safest method of transfer.Cognitive Level: ComprehensionNCLEX Blueprint: Reduction in Risk Potential • Question 10 1 out of 1 points A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the nurse is most accurate? Correct Answer: A. “Everyone who enters your room must wear a mask to protect themselves from tuberculosis.” Response Feedback : Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask. Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease again. Cognitive Level: ApplicationNCLEX Blueprint: Safety and Infection Control • Question 11 1 out of 1 points The nurse is removing personal protective equipment (PPE). Which item should be removed first? Correct Answer: B. Gloves Response Feedback : The gloves are removed first because they are usually the most contaminated PPE and must be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed second, then the mask or face shield, and finally, the hair covering.Cognitive level: applicationNCLEX Blueprint: Safety and infection control • Question 12 1 out of 1 points For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? Correct Answer: B. Hypertensi on Response Feedback : Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.Cognitive Level: ComprehensionNCLEX Blueprint: Physiological Adaptation • Question 13 1 out of 1 points The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the client’s abdomen and notes that there are no bowel sounds. What action does the nurse take? Correct Answer: D. Document the finding and continue to monitor. Response Feedback: Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.Cognitive Learning: applicationNCLEX Blueprint: Pharmacological and Parental therapy • Question 14 1 out of 1 points Which of the following is false regarding state licensure laws? Correct Answer: B. Licensure is not necessary if the individual has completed training. Response Feedback : Licensure is required to practice after the completion of all required training for the profession. The state laws establish the requirements to practice and the state regulatory agencies are responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is legally authorized to perform.Cognitive level: applicationNCLEX Blueprint: Management of care .....