©BRIGHTSTARS EXAM SOLUTIONS
10/21/2024 9:24 PM
NCLEX® Examination Challenges Unit 1
Exam Questions And Answers 100% Pass
Which statement by an older adult regarding diet and exercise indicates a need for further
teaching by the nurse? - answer✔"I will stop drinking fluids after 4 PM to prevent getting up
during the night."
Older adults need to drink adequate fluids to prevent constipation and dehydration. Therefore,
the nurse needs to provide health teaching about this important healthy behavior.
A home care nurse conducts an assessment of an older woman's medications and herbal/
nutritional supplements. Which supplement is most likely to cause an interaction with prescribed
medications? - answer✔St. John's wort
St. John's wort interacts with many prescribed drugs by either decreasing their effectiveness or
increasing drug action. Examples of prescribed drugs that interact with this herb include
antihistamines, antidepressants, digoxin, sedatives, immune suppressing agents, warfarin, and
anti-allergy medications. Calcium and vitamin B complex do not commonly interact with most
prescribed medication. Excessive vitamin C could cause bleeding and bruising, but as a water-
soluble vitamin, this supplement is relatively safe to use.
An older adult returns to the orthopedic unit after an open reduction, internal fixation surgery for
a fractured hip. Upon admission, she is combative and screaming profane language. What is the
nurse's first action? - answer✔Assess for risk factors that could cause her behaviors.
The client's behaviors are consistent with delirium, or short-term acute confusion. This problem
is common after surgery in older adults, especially hip repairs. The nurse needs to determine the
cause of the delirium to manage it. Oxygen therapy may not be needed. Increasing IV fluids
might cause fluid overload. Morphine often causes delirium in older adults.
, ©BRIGHTSTARS EXAM SOLUTIONS
10/21/2024 9:24 PM
A client who had a laminectomy reports new onset of severe back pain. What responses by the
nurse are most appropriate for the client at this time? Select all that apply. - answer✔"Can you
tell me what positions make the pain feel worse and better?"
"How is your pain on a 0-10 scale with 10 being the worst possible pain you've had?"
"Could you describe the pain in your back?"
Before the nurse intervenes to manage the patient's pain, he or she needs to do a complete pain
assessment to collect more information. The statement "When you had visitors, you seemed to be
laughing and not in any pain" is questioning the client's report of pain. Pain is subjective and is
what the client says that it is.
An older client takes acetaminophen (Tylenol) 2000 mg daily for osteoarthritis. What health
teaching will the nurse provide for the client related to this medication? - answer✔"Avoid any
over-the-counter medications that may contain acetaminophen."
Many over-the-counter drugs contain acetaminophen, which when combined with the maximum
prescribed dose of 3000 mg can cause liver toxicity. Acetaminophen does not cause stomach
ulcers or increased blood pressure like other nonsteroidal antiinflammatory drugs can. Drugs for
chronic pain should be taken on a regular regimen, not "as needed."
A client has a one-time order for morphine 2 mg IV push. The drug is available as 5 mg/mL. The
nurse administers _____ mL of morphine for one dose - answer✔0.4
The available 1 mL of solution contains 5 mg of the drug. Therefore, to give 2 mg, less than 1
mL would be given. Using dimensional analysis or ratio and proportion, 2/5 = 0.4.
A nursing technician reports that a postoperative client who is receiving IV PCA morphine is
very drowsy, unable to complete a sentence without falling asleep, and has a respiratory rate of
12 breaths per minute. What is the nurse's first action at this time? - answer✔Promptly call the
primary health care provider to request an order to reduce the opioid dose.
The client's assessment findings are consistent with PCA morphine administration. The nurse
continues to monitor the client's level of consciousness and assesses the respiratory rate
frequently to determine if opioid overdose occurs.
10/21/2024 9:24 PM
NCLEX® Examination Challenges Unit 1
Exam Questions And Answers 100% Pass
Which statement by an older adult regarding diet and exercise indicates a need for further
teaching by the nurse? - answer✔"I will stop drinking fluids after 4 PM to prevent getting up
during the night."
Older adults need to drink adequate fluids to prevent constipation and dehydration. Therefore,
the nurse needs to provide health teaching about this important healthy behavior.
A home care nurse conducts an assessment of an older woman's medications and herbal/
nutritional supplements. Which supplement is most likely to cause an interaction with prescribed
medications? - answer✔St. John's wort
St. John's wort interacts with many prescribed drugs by either decreasing their effectiveness or
increasing drug action. Examples of prescribed drugs that interact with this herb include
antihistamines, antidepressants, digoxin, sedatives, immune suppressing agents, warfarin, and
anti-allergy medications. Calcium and vitamin B complex do not commonly interact with most
prescribed medication. Excessive vitamin C could cause bleeding and bruising, but as a water-
soluble vitamin, this supplement is relatively safe to use.
An older adult returns to the orthopedic unit after an open reduction, internal fixation surgery for
a fractured hip. Upon admission, she is combative and screaming profane language. What is the
nurse's first action? - answer✔Assess for risk factors that could cause her behaviors.
The client's behaviors are consistent with delirium, or short-term acute confusion. This problem
is common after surgery in older adults, especially hip repairs. The nurse needs to determine the
cause of the delirium to manage it. Oxygen therapy may not be needed. Increasing IV fluids
might cause fluid overload. Morphine often causes delirium in older adults.
, ©BRIGHTSTARS EXAM SOLUTIONS
10/21/2024 9:24 PM
A client who had a laminectomy reports new onset of severe back pain. What responses by the
nurse are most appropriate for the client at this time? Select all that apply. - answer✔"Can you
tell me what positions make the pain feel worse and better?"
"How is your pain on a 0-10 scale with 10 being the worst possible pain you've had?"
"Could you describe the pain in your back?"
Before the nurse intervenes to manage the patient's pain, he or she needs to do a complete pain
assessment to collect more information. The statement "When you had visitors, you seemed to be
laughing and not in any pain" is questioning the client's report of pain. Pain is subjective and is
what the client says that it is.
An older client takes acetaminophen (Tylenol) 2000 mg daily for osteoarthritis. What health
teaching will the nurse provide for the client related to this medication? - answer✔"Avoid any
over-the-counter medications that may contain acetaminophen."
Many over-the-counter drugs contain acetaminophen, which when combined with the maximum
prescribed dose of 3000 mg can cause liver toxicity. Acetaminophen does not cause stomach
ulcers or increased blood pressure like other nonsteroidal antiinflammatory drugs can. Drugs for
chronic pain should be taken on a regular regimen, not "as needed."
A client has a one-time order for morphine 2 mg IV push. The drug is available as 5 mg/mL. The
nurse administers _____ mL of morphine for one dose - answer✔0.4
The available 1 mL of solution contains 5 mg of the drug. Therefore, to give 2 mg, less than 1
mL would be given. Using dimensional analysis or ratio and proportion, 2/5 = 0.4.
A nursing technician reports that a postoperative client who is receiving IV PCA morphine is
very drowsy, unable to complete a sentence without falling asleep, and has a respiratory rate of
12 breaths per minute. What is the nurse's first action at this time? - answer✔Promptly call the
primary health care provider to request an order to reduce the opioid dose.
The client's assessment findings are consistent with PCA morphine administration. The nurse
continues to monitor the client's level of consciousness and assesses the respiratory rate
frequently to determine if opioid overdose occurs.
