Nclex Cris 2-50 Exam Questions With Correct Answers

The nurse supervises the transfer of an elderly client with left-sided weakness from the bed to the chair. After assisting the client to a sitting position, which of the following actions should the nurse take NEXT? 1. Place nonskid shoes on the client's feet. 2. Instruct the client that she will be moving toward her left side. 3. Ask the client to pivot on her right foot. 4. Support the left leg with the nurse's knee. - ANS Strategy: Determine the outcome of each answer. 1) CORRECT— instruct client to wear shoes when transferring, nonskid soles decrease the chance of falls 2) if client has weaker side, transfer toward the stronger side; nurse should assess if a transfer belt is required; place chair at 45° angle to the bed 3) appropriate action; first put shoes on client; instruct client to use armrests on chair for support 4) appropriate action to provide stability to weak leg so that client can stand during transfer A 16-year-old girl is brought to the emergency room by her parents for evaluation of an eating disorder. When the nurse approaches the client to draw a blood sample, the client cries out, "I hate having my blood drawn. Go away!" Which of the following responses by the nurse is BEST? 1. "What's the matter? Are you afraid of what we are going to find?" 2. "What is it about having your blood drawn that upsets you?" 3. "Take a deep breath. It will be over before you know it." 4. "I'll be back in 15 minutes so we can discuss your concern." - ANS Strategy: "BEST" indicates discrimination is required to answer the question. 1) yes/no question; nurse is making an assumption 2) CORRECT— open-ended; relates to client's verbal and nonverbal communication and responds to the client's feelings 3) "don't worry" response; nontherapeutic 4) do not leave the client alone The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a prenatal visit on June 6. Her last menstrual period was December 10. The nurse expects the client's fundal height to measure 1. 24 cm. 2. 26 cm. 3. 28 cm. 4. 30 cm. - ANS Strategy: Think about each answer. 1) incorrect, determine EDC based on N ä gele's rule-date LMP Dec. 10; EDB-Sept. 17; client is 26 weeks pregnant; from 24-34 weeks, fundal height correlates well with weeks of gestation; 24 cm is approximately 24 weeks' gestation 2) CORRECT— client is 26 weeks pregnant; fundal height should correlate with weeks of pregnancy 3) fundus is too high 4) fundus is too high Recently several s