Elevate 5. NCLEX Review Questions with answers. With Explanations. Graded A+

Elevate 5. NCLEX Review Questions with answers. With Explanations. Graded A+ Document Content and Description Below Elevate 5. NCLEX Review Questions with answers. With Explanations. Graded A+ The nurse is working on interventions for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the plan? 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly. - 1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. 4. Incorrect: Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate. A nurse utilizes the Braden Scale to assess and document the pressure sore risk of a client diagnosed with Guillain-Barré syndrome. 0900 Nursing Documentation: The client has very limited sensory perception and is incontinent of urine. The client is wheelchair bound and has very limited mobility. The client is receiving adequate caloric intake by tube feeding and is moved easily by the nursing staff without any evidence of friction or shearing. Based on this nursing documentation, what score should the nurse assign to this client? - The nurse should assign a Braden Scale score of 13 to this client. According to the Braden Scale criteria, the client should score a 2 in sensory perception; a 1 in moisture; a 2 in activity; a 2 in mobility; a 3 in nutrition; and a 3 in friction and shear. A total score of 13 indicates that the client has a moderate risk for developing pressure ulcers at this time. The Braden Scale Assessment Score: Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23 A client arrives in the emergency department with suspected methamphetamine intoxication. The client is extremely agitated with violent outbursts, hypertensive, and tachycardic. What treatment should the nurse anticipate for this client? 1. Droperidol 2. Lorazepam 3. Methylphenidate 4. Dexmethylphenidate 5. Labetalol 6. Nitroprusside - 1., 2., 5., & 6 Correct: What cues did you pick up in the stem? This client is agitated, violent, hypertensive and tachycardic. Would the heart tolerate this for a long time period? No! This is a situation that should be managed quickly. So, how can we best manage this client with methamphetamine intoxication? Let's consider the extreme agitation and violent outbursts. What would be effective in reducing these behaviors? You may be thinking of Inapsine (droperidol) as an antiemetic agent, but are you aware that it is used to produce marked tranquilization, sedation, and a reduction in anxiety? In clients with methamphetamine intoxication, droperidol can produce more rapid and significant sedation than Ativan (lorazepam), but both droperidol and lorazepam can be useful in these clients to not only reduce the agitation and produce sedation, but they can also help reduce the pulse and systolic blood pressure. If the hypertension and tachycardia continues despite the use of droperidol and/or lorazepam, the client may be given a beta-blocker and vasodilator to manage these symptoms. Labetalol is the preferred beta-blocker because of its combined anti-alpha-adrenergic and anti-beta-adrenergic effects. Vasodilators, such as nitroprusside, may be used to help lower the blood pressure. 3. Incorrect: Ritalin (methylphenidate) is a CNS stimulant. Do we need to cause CNS stimulation in this client? No!! This would be dangerous to give a client who is already extremely agitated, has hypertension and tachycardia, and is at risk of having seizures. 4. Incorrect: Focalin (dexmethylphenidate) is also a CNS stimulant and would not be appropriate treatment for this client with hypertension and tachycardia. We would never want to give the client something that would worsen the symptoms! A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massage the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Acupuncture may provide great improvement in symptoms. - 3. Correct: Even though all are educational points that need to be provided to the client, this is the most important point. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 1. Incorrect: Physical therapy will be needed, however care to prevent eye injury takes priority. 2. Incorrect: This can be done once the client's facial sensitivity to touch decreases and the client can tolerate touching the face. Preventing eye injury takes priority. 4. Incorrect: Acupuncture may provide a potential small improvement in function. The priority however, is protection of the eye. The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min, arterial BP 98/48, oxygen saturation 82%, cardiac monitor showing sinus tachycardia at 138 bpm. What action should the nurse take first? 1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 settings to 100%. 3. Hyperventilate client. 4. Auscultate lung sounds. - 4. Correct: When an alarm sounds, the first action by the nurse is to assess the client. In this situation, assessment of lung sounds, chest movement, and respiratory effort should indicate which respiratory complication the client may be experiencing. Depending on the assessment findings, the other actions may be necessary. 1. Incorrect: Depending on the assessment findings, the other actions may be necessary. Check the ventilator after checking the client. 2. Incorrect: Depending on the assessment findings, the other actions may be necessary. 3. Incorrect: Depending on the assessment findings, the other actions may be necessary. A primary healthcare provider documents the following Glasgow Coma Scale score in a client's medical record: "GCS 9 = E2 V4 M3 at 0720". What conclusions should a nurse draw from this documentation? 1. A severe head injury has been sustained. 2. The client opens the eyes in response to a pain stimulus. 3. The client's speech is incomprehensible. 4. Abnormal flexion is observed in the client. 5. The GCS assessment was performed at 7:20 am. - 2., 4., & 5. Correct: A score of "E2" indicates that the client opens the eyes only in response to a pain stimulus. A score of "M3" indicates that the client is exhibiting abnormal spastic flexion of the body (decorticate posture) and "0720" indicates that the assessment was conducted at 7:20 am. 1. Incorrect: "GCS 9" indicates that the client has sustained a moderate head injury. 3. Incorrect: "V4" indicates that the client is able to speak, but is confused and/or disoriented. A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? 1. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 2. Use a new cotton ball for each cleansing wipe. 3. Instill artificial tears into the lower eye lids as prescribed. 4. Protect the eyes with a protective shield. 5. Monitor eyes for redness, and exudate. - 2., 3., 4., & 5. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions will prevent infection, keep eyes moist, and protect the eyes from injury. 1. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct. A client with a head injury manifests symptoms of increasing intracranial pressure. The primary healthcare provider prescribes mannitol IV. How would the nurse plan to evaluate the effectiveness of this medication? 1. Monitor urine output hourly 2. Take vital signs every 15 minutes 3. Measure head circumference every 8 hours 4. Assess the level of consciousness (LOC) every hour - 4. Correct: The stem of the question states the client manifests symptoms of increased ICP. Assessing the LOC is the only answer that assesses for increased ICP. Even if you do not know how mannitol works, the only answer that assesses the client for increased ICP is to assess the LOC. 1. Incorrect: Mannitol causes an osmotic diuresing effect. Urinary output Show Less Last updated: 8 months ago