KAPLAN TEST NCLEX QUESTION TRAINER TEST 4 - $12.49   Add to cart

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KAPLAN TEST NCLEX QUESTION TRAINER TEST 4

NCLEX QUESTION TRAINER TEST 4 1. A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? "Morphine sulfate 10 mg IM q3 4h." 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h." Strategy: "Question which of the following orders" indicates an incorrect order. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers 2. The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? A man complains of heartburn that radiates to the jaw. 1. A woman in the first trimester of pregnancy complains of heartburn. 2. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball. Strategy: Determine the least stable client. (1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice 3. A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? Head of bed elevated 60–90°. 1. Head of bed elevated 30–45°. 2. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side. Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position 4. The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? Cool skin, respiratory crackles, pulse 86 and bounding. 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus. Strategy: (1) indicates dehydration (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen 5. A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? "How long have you been in remission?" 1. "Most women find that they feel better when they are pregnant." 2. 3. "Women with lupus frequently have slightly longer gestations." 4. "It is best to become pregnant within the first 6 months of diagnosis." Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving 6. The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program 7. A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? Diaphoresis and trembling. 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. 4. Headache and polyuria. Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia 8. The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? Talk with the client about how the client is feeling. 1. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now 9. The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section contains lower amounts of narcotics than are given before general surgery. 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. 4. contains medications similar in type and dosages to those given before general surgery. Strategy: Think about the action of the medications. (1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant (4) dosages of narcotics are reduced 10. The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? Place a trochanter roll on the outer aspect of the thigh. 1. 2. Perform resistive range of motion of the left leg. 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment 11. The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure 12. The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. Reassess in 5 minutes. 2. Check the client's visual acuity. 3. Lower the head of the client's bed. Contact the physician. 4. Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations. (1) assessment; situation does not require validation (2) assessment; has symptoms of increased intracranial pressure (ICP) (3) implementation; would increase the ICP (4) correct—implementation; fixed and dilated pupil represents a neurological emergency 13. A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? The child closes one eye to see a poster on the wall. 1. The child places his head close to the table when drawing. 2. The child rubs his eyes frequently. 3. 4. The child is unable to see objects in the periphery of his visual field. Strategy: Think about each answer choice. (1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision 14. The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via face mask or nasal prongs. Administer naloxone (Narcan). 3. 4. Place epinephrine 1:1,000 at the bedside. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be given Narcan for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action (4) unnecessary 15. The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? "I should induce vomiting if my child swallows lighter fluid." 1. "The poison control center number is stored on all the phones in our house." 2. 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home." Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets 16. The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? Serve the meal to the client in the seclusion room. 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety 17. Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage peers to visit on a regular basis. Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority 18. The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA. 2. Order three additional units of NPH insulin at 10 P.M. 3. Order an additional 10 units of regular insulin at 8 P.M. 4. Eliminate the client's bedtime snack. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should not be reduced (2) correct—dawn phenomena, treatment is to adju

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