NCLEX Question Trainer
Explanations Test 7
1. The Father Of A One-Day-Old Son Works The Evening Shift (3 Pm To 11
Pm) At Another Hospital. Which Of The Following Plans Would Be A Priority
To Meet The Needs Of This Father?
1. Encourage The Father To Call His Wife After Work.
2. Instruct The Father About Visiting Policy And Suggest Am Visitation.
3. Adjust Visiting Hours To Meet The New Parents’ Needs.
4. Present A Change Of Visiting Hours To The Appropriate Hospital
Committee.
Strategy: Answers Are Implementation. Determine The Outcome Of Each
Answer. Is It Desired?
(1) Inflexible
(2) Inflexible
(3) Correct–Role Of Nurse Is To Be A Family And Client Advocate; This
Provides Individualized Care Not A Priority, Although It May Be An
Appropriate Long-Range Goal
(4) Not A Priority, Although It May Be An Appropriate Long-Range Goal
2. The Nurse Believes A Coworker Is Diverting Narcotics. The Nurse
Approaches The Nurse Manager To Report The Suspicions. Which Of The
Following Statements By The Nurse Is Best?
,1. “After My Coworker Has Been On Duty, The Patients Often Need
Repeated Doses Of Pain Medication. I Have Seen Her/Him Sleeping On Duty
Three Times.”
2. “I Saw My Coworker Downtown After Work. S/He Was Acting Really
Strange, Like S/He Didn’t Even Recognize Me.”
3. “I Think My Coworker Is Stealing Narcotics Because S/He Is Always
Acting Euphoric And Seems High.”
4. “My Coworker Is Hanging Around With Drug Dealers, And I Think I Saw
Tracks On Her/His Arms.”
Strategy: All Answers Are Assessment. Determine How Each Relates To The
Situation.
(1) Correct—Report Objective Information That Can Be Verified; Clues To
Possible Substance Abuse By Staff Include Memory Lapses, Frequent
Absences From The Floor, Increased Number Of Clients Reporting Unrelieved
Pain Or Insomnia
(2) Subjective Observation
(3) Subjective Observation
(4) “Hanging Around With Drug Dealers” Is Subjective
3. A Woman With Chronic Obstructive Pulmonary Disease (Copd) Is
Admitted With An Acute Exacerbation. Her Vital Signs Are: Bp 162/100, Pulse
78, Respirations 30 And Labored With Wheezing. The Nurse Should Question
Which Of The Following Orders?
1. Theophylline (Somophyllin) 0.7 Mg/Kg/Hr Iv.
2. Tetracycline Hydrochloride (Sumycin) 250 Mg Im Qd.
3. Ipratropium Bromide (Atrovent) Inhaler 2 Inhalations Qid.
4. Propranolol Hydrochloride (Inderal) 40 Mg Po Bid.
,Strategy: You Are Looking For An InCorrect Medication. Think About The
Action Of Each Drug.
(1) Drug Of Choice For Acute Asthma
(2) Broad Spectrum Antibiotic, Not Contraindicated
(3) Blocks Parasympathetic Stimulation And Decreases Mucus; Used With
Asthma
(4) Correct—Beta-Blocker That Blocks Beta Adrenergic Impulses To The
Bronchial Tree That Cause Bronchodilation Resulting In Increased
Bronchoconstriction
4. A Husband And Wife Meet At The Mental Health Clinic To Make An
Appointment For Family Therapy. Suddenly, The Wife Begins To Sob Loudly.
As The Nurse Approaches, The Husband Says, “I Guess We Just Don’t Get
Along.” Which Of The Following Responses By The Nurse Is Most
Appropriate?
1. “Your Wife Seems To Be Upset By The Situation.”
2. “Perhaps You Should Both Go Home Now.”
3. “Try To Think About What Precipitated Her Crying.”
4. “The Situation Is Difficult For Both Of You.”
Strategy: Remember Therapeutic Communication.
(1) Nontherapeutic; Emphasis Is Placed On Wife, Not The Situation
(2) Nontherapeutic; Closes Off Communication
(3) Nontherapeutic; Appears To Blame The Husband For Precipitating The
Wife’s Behavior, Would Cause Him To React Defensively
(4) Correct—Therapeutic; Avoids Blaming, Focuses On Feelings Of Both
Husband And Wife
5. A Client On Chemotherapy Has A Wbc Count Of 1,200/Mm3. Which Of
The Following Nursing Actions Should The Nurse Take First?
, 1. Check Temperature Q4h.
2. Monitor Urine Output.
3. Assess For Bleeding Gums.
4. Obtain An Order For Blood Cultures.
Strategy: Determine How Each Assessment Relates To A Low White Count.
(1) Correct—Important To Monitor For Infection Which Would Be Evidenced
By An Elevated Temperature In A Client With A Low Wbc
(2) Important Because Of Problems Of Increased Uric Acid Excretion From
Chemotherapeutic Drugs But Should Not Be Done First
(3) Would Be Associated With A Low Platelet Count
(4) Would Be Done If The Temperature Were Elevated To Determine The
Type Of Organism Involved
6. A Woman Is In Active Labor With Her First Child When Her Membranes
Rupture. She Voices A Concern To The Nurse That She Is Afraid Of Having A
“Dry Labor.” Which Of The Following Responses By The Nurse Would Be Most
Appropriate?
1. “The Amniotic Fluid Provides Only Minimal Lubrication For The Labor
Process.”
2. “The Amniotic Sac May Impede The Progress Of Labor And Is Often
Ruptured Artificially.”
3. “Labor Is Only Slightly More Difficult With Early Rupture Of The
Amniotic Sac.”
4. “Because There Is Limited Amniotic Fluid, Additional Fluids Will Be
Supplied.”
Strategy: “Most” Indicates There May Be More Than One Answer That You
Like.
Explanations Test 7
1. The Father Of A One-Day-Old Son Works The Evening Shift (3 Pm To 11
Pm) At Another Hospital. Which Of The Following Plans Would Be A Priority
To Meet The Needs Of This Father?
1. Encourage The Father To Call His Wife After Work.
2. Instruct The Father About Visiting Policy And Suggest Am Visitation.
3. Adjust Visiting Hours To Meet The New Parents’ Needs.
4. Present A Change Of Visiting Hours To The Appropriate Hospital
Committee.
Strategy: Answers Are Implementation. Determine The Outcome Of Each
Answer. Is It Desired?
(1) Inflexible
(2) Inflexible
(3) Correct–Role Of Nurse Is To Be A Family And Client Advocate; This
Provides Individualized Care Not A Priority, Although It May Be An
Appropriate Long-Range Goal
(4) Not A Priority, Although It May Be An Appropriate Long-Range Goal
2. The Nurse Believes A Coworker Is Diverting Narcotics. The Nurse
Approaches The Nurse Manager To Report The Suspicions. Which Of The
Following Statements By The Nurse Is Best?
,1. “After My Coworker Has Been On Duty, The Patients Often Need
Repeated Doses Of Pain Medication. I Have Seen Her/Him Sleeping On Duty
Three Times.”
2. “I Saw My Coworker Downtown After Work. S/He Was Acting Really
Strange, Like S/He Didn’t Even Recognize Me.”
3. “I Think My Coworker Is Stealing Narcotics Because S/He Is Always
Acting Euphoric And Seems High.”
4. “My Coworker Is Hanging Around With Drug Dealers, And I Think I Saw
Tracks On Her/His Arms.”
Strategy: All Answers Are Assessment. Determine How Each Relates To The
Situation.
(1) Correct—Report Objective Information That Can Be Verified; Clues To
Possible Substance Abuse By Staff Include Memory Lapses, Frequent
Absences From The Floor, Increased Number Of Clients Reporting Unrelieved
Pain Or Insomnia
(2) Subjective Observation
(3) Subjective Observation
(4) “Hanging Around With Drug Dealers” Is Subjective
3. A Woman With Chronic Obstructive Pulmonary Disease (Copd) Is
Admitted With An Acute Exacerbation. Her Vital Signs Are: Bp 162/100, Pulse
78, Respirations 30 And Labored With Wheezing. The Nurse Should Question
Which Of The Following Orders?
1. Theophylline (Somophyllin) 0.7 Mg/Kg/Hr Iv.
2. Tetracycline Hydrochloride (Sumycin) 250 Mg Im Qd.
3. Ipratropium Bromide (Atrovent) Inhaler 2 Inhalations Qid.
4. Propranolol Hydrochloride (Inderal) 40 Mg Po Bid.
,Strategy: You Are Looking For An InCorrect Medication. Think About The
Action Of Each Drug.
(1) Drug Of Choice For Acute Asthma
(2) Broad Spectrum Antibiotic, Not Contraindicated
(3) Blocks Parasympathetic Stimulation And Decreases Mucus; Used With
Asthma
(4) Correct—Beta-Blocker That Blocks Beta Adrenergic Impulses To The
Bronchial Tree That Cause Bronchodilation Resulting In Increased
Bronchoconstriction
4. A Husband And Wife Meet At The Mental Health Clinic To Make An
Appointment For Family Therapy. Suddenly, The Wife Begins To Sob Loudly.
As The Nurse Approaches, The Husband Says, “I Guess We Just Don’t Get
Along.” Which Of The Following Responses By The Nurse Is Most
Appropriate?
1. “Your Wife Seems To Be Upset By The Situation.”
2. “Perhaps You Should Both Go Home Now.”
3. “Try To Think About What Precipitated Her Crying.”
4. “The Situation Is Difficult For Both Of You.”
Strategy: Remember Therapeutic Communication.
(1) Nontherapeutic; Emphasis Is Placed On Wife, Not The Situation
(2) Nontherapeutic; Closes Off Communication
(3) Nontherapeutic; Appears To Blame The Husband For Precipitating The
Wife’s Behavior, Would Cause Him To React Defensively
(4) Correct—Therapeutic; Avoids Blaming, Focuses On Feelings Of Both
Husband And Wife
5. A Client On Chemotherapy Has A Wbc Count Of 1,200/Mm3. Which Of
The Following Nursing Actions Should The Nurse Take First?
, 1. Check Temperature Q4h.
2. Monitor Urine Output.
3. Assess For Bleeding Gums.
4. Obtain An Order For Blood Cultures.
Strategy: Determine How Each Assessment Relates To A Low White Count.
(1) Correct—Important To Monitor For Infection Which Would Be Evidenced
By An Elevated Temperature In A Client With A Low Wbc
(2) Important Because Of Problems Of Increased Uric Acid Excretion From
Chemotherapeutic Drugs But Should Not Be Done First
(3) Would Be Associated With A Low Platelet Count
(4) Would Be Done If The Temperature Were Elevated To Determine The
Type Of Organism Involved
6. A Woman Is In Active Labor With Her First Child When Her Membranes
Rupture. She Voices A Concern To The Nurse That She Is Afraid Of Having A
“Dry Labor.” Which Of The Following Responses By The Nurse Would Be Most
Appropriate?
1. “The Amniotic Fluid Provides Only Minimal Lubrication For The Labor
Process.”
2. “The Amniotic Sac May Impede The Progress Of Labor And Is Often
Ruptured Artificially.”
3. “Labor Is Only Slightly More Difficult With Early Rupture Of The
Amniotic Sac.”
4. “Because There Is Limited Amniotic Fluid, Additional Fluids Will Be
Supplied.”
Strategy: “Most” Indicates There May Be More Than One Answer That You
Like.
