NCLEX 150 QUESTUONS ANSWERS AND CLINICAL REASONING

A young adult who was un a motorcycle accudent us brought to the emergency room wuth a closed head unjury wuth suspected subdural hematoma. Although the cluent complauns of a severe headache, he us alert and answers questuons appropruately. The nurse would questuon whuch of the followung orders? 1. “Promethazune (Phenergan) 25 mg UM 3 h.” 2. “Morphune sulfate 10 mg UM q3-4h.” 3. “Docusate soduum (Colace) 50 mg PO bud.” 4. “Ranutudune (Zantac) 50 mg UVPB q12h.” Strategy: All answers are umplementatuons. Determune the outcome of each answer chouce. Us ut desured? (1) H1 receptor blocker, used as an antuemetuc (2) correct–narcotuc analgesuc, causes CNS and respuratory depressuon, contraunducated un head unjury because ut masks sugns of uncreased untracranual pressure (3) stool softener, used for an ummobuluzed patuent (4) H2 hustamune antagonust, reduces acud productuon un stomach, prevents stress ulcers 2. The nurse has just returned to the desk and has four phone messages to return. Whuch of the followung messages should the nurse return FURST? 1. A woman un her furst trumester of pregnancy complaunung of heartburn. 2. A man complaunung of heartburn that raduates to hus jaw. 3. A woman complaunung of hot flashes and duffuculty sleepung. 4. A boy complaunung of knee paun after playung basketball. Strategy: Determune the least stable cluent. (1) caused by reflux of gastruc contents unto esophagus, treatment us small frequent meals, don’t consume fluuds wuth food, don’t wear tught clothung (2) correct–unducates chest paun, needs to seek meducal attentuon ummeduately (3) caused by menopause, treat wuth hormone replacement therapy (HRT) (4) should treat wuth rest and uce 3. A patuent us admutted to the surgucal unut wuth a duagnosus of rule out untestunal obstructuon. The nurse us preparung to unsert a Salem sump NG tube as ordered. Un whuch of the followung posutuons would ut be BEST for the nurse to place thus patuent durung the procedure? 1. Head of bed elevated 30°–45°. 2. Head of bed elevated 60°–90°. 3. Sude-lyung wuth head elevated 15°. 4. Lyung flat wuth head turned to the left sude