• Question 1
1 out of 1 points
Which dietary adjustments does the nurse recommend to an older adult
client asking what changes she should institute to prevent or manage
constipation?
Correct C.
Answer:
“Include plenty of
fiber.”
Response Older adults are prone to constipation. To manage or prevent
Feedback
:
constipation, teach the older client to drink eight glasses of
water daily and to take in plenty of fiber.These guidelines are
good for other clients as well. The other suggestions will not
prevent or help manage constipation.Cognitive Level:
ComprehensionNCLEX Blueprint: Health Promotion and
Maintenance (Self-Care)
• Question 2
0 out of 1 points
The strategy to avoid medication errors endorsed by the Institute for Safe
Medication Practices (ISMP) to differentiate products with look-alike
names is referred to as
Correct D.
Answer:
tallman lettering.
Response Tallman lettering is a term coined by ISMP to describe the
Feedback
:
practice of using unique letter characteristics of similar drug
names known to have been confused withone another.
Tallman lettering is used to differentiate
, products with look-alike names such as BenaDRYL
(antihistamine) and BenaZEPRIL (ace inhibitor). The other
options are examples of safety-enhancing technologies
strategies designed to minimize drug errors, but they are not
directed at look-alike medications. Automatic alerts are
computer-generated alarms that can be programmed to occur
with such things as allergies and incompatible medications.
Bar coding is used with medication administration systems
that can be programmed to match patient identificationbracelets
with documentation. Computer order entry systems are
designed to include components of a standard medication
order.Cognitive level: applicationNCLEX Blueprint:
Pharmacology and Parentaltherapies
• Question 3
1 out of 1 points
A home care nurse receives a physician order for a medication that the
patient does not want to take because the patient has a historyof side effects
from this medication. The nurse carefully listens to the patient, considers it
in light of the patient's condition, questionsits appropriateness, and examines
alternative treatments. This nurse would most likely
Correct A.
Answer:
call the physician, explain rationale, and suggest adifferent
medication.
Response Determining how best to proceed on behalf of a patient's best
Feedback
:
health care outcomes may require clinical judgment. At the
committed level of critical thinking, thenurse 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 physicianis 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 nurseknows that
which effect could have led to such a condition?
Correct D.
Answer:
Loss of muscle
tone
Response The nurse should know that the loss of muscle tone leads to
Feedback
:
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 daughterasks
what this means. What is the nurse’s best response?
Correct A.
Answer:
, “The surgery will relieve the symptoms but will notcure your
father.”
Response The purpose of palliative surgery is to improve the client’s
Feedback:
quality of life by reducing or eliminating distressing
symptoms. It does not cure a health problemand 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 B.
Answer:
low birthweight.
Response Low birth weight and poorly nourished infants (particularly
Feedback
:
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 behypothermic
would be to
Correct D.
Answer:
1 out of 1 points
Which dietary adjustments does the nurse recommend to an older adult
client asking what changes she should institute to prevent or manage
constipation?
Correct C.
Answer:
“Include plenty of
fiber.”
Response Older adults are prone to constipation. To manage or prevent
Feedback
:
constipation, teach the older client to drink eight glasses of
water daily and to take in plenty of fiber.These guidelines are
good for other clients as well. The other suggestions will not
prevent or help manage constipation.Cognitive Level:
ComprehensionNCLEX Blueprint: Health Promotion and
Maintenance (Self-Care)
• Question 2
0 out of 1 points
The strategy to avoid medication errors endorsed by the Institute for Safe
Medication Practices (ISMP) to differentiate products with look-alike
names is referred to as
Correct D.
Answer:
tallman lettering.
Response Tallman lettering is a term coined by ISMP to describe the
Feedback
:
practice of using unique letter characteristics of similar drug
names known to have been confused withone another.
Tallman lettering is used to differentiate
, products with look-alike names such as BenaDRYL
(antihistamine) and BenaZEPRIL (ace inhibitor). The other
options are examples of safety-enhancing technologies
strategies designed to minimize drug errors, but they are not
directed at look-alike medications. Automatic alerts are
computer-generated alarms that can be programmed to occur
with such things as allergies and incompatible medications.
Bar coding is used with medication administration systems
that can be programmed to match patient identificationbracelets
with documentation. Computer order entry systems are
designed to include components of a standard medication
order.Cognitive level: applicationNCLEX Blueprint:
Pharmacology and Parentaltherapies
• Question 3
1 out of 1 points
A home care nurse receives a physician order for a medication that the
patient does not want to take because the patient has a historyof side effects
from this medication. The nurse carefully listens to the patient, considers it
in light of the patient's condition, questionsits appropriateness, and examines
alternative treatments. This nurse would most likely
Correct A.
Answer:
call the physician, explain rationale, and suggest adifferent
medication.
Response Determining how best to proceed on behalf of a patient's best
Feedback
:
health care outcomes may require clinical judgment. At the
committed level of critical thinking, thenurse 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 physicianis 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 nurseknows that
which effect could have led to such a condition?
Correct D.
Answer:
Loss of muscle
tone
Response The nurse should know that the loss of muscle tone leads to
Feedback
:
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 daughterasks
what this means. What is the nurse’s best response?
Correct A.
Answer:
, “The surgery will relieve the symptoms but will notcure your
father.”
Response The purpose of palliative surgery is to improve the client’s
Feedback:
quality of life by reducing or eliminating distressing
symptoms. It does not cure a health problemand 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 B.
Answer:
low birthweight.
Response Low birth weight and poorly nourished infants (particularly
Feedback
:
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 behypothermic
would be to
Correct D.
Answer:
