NCLEX QUESTIONS TESTBANK

NCLEX questions The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply 1) Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctionin 3)The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure. Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. 4) A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? Fried haddock, baked potato, and a cola drink Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required while on this medication to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs; bananas; aged cheese; yogurt and sour cream beer, red wine, and other alcoholic beverages; soy sauce; yeastextract; chocolate; caffeine; and aged, pickled, fermented, or smoked foods need to be avoided. 5) A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? White blood cell count Rationale: A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication. 6) A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence? Paradoxical bronchospasm, which must be reported to the health care provider (HCP) Rationale: The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication should be withheld and the HCP should be notified. The remaining options are incorrect interpretations. A client taking verapamil has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? Rationale Verapamil is a calcium channel blocker. The most common complaint with the use of verapamil is constipation. Other frequent side effects are dizziness, facial flushing, headache, and edema of the hands and feet. Weight loss, nasal stuffiness, and abdominal cramping are not associated with the use of this medication 7) A client taking verapamil has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? Constipation Rat: Verapamil is a calcium channel blocker. The most common complaint with the use of verapamil is constipation. 8 A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan? Supportive treatment Rat: With viral pneumonia, treatment is supportive 9) On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? Conjunctival hyperemia Rat: Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. 12. The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. Hemodialysis Kidney transplant Bilateral nephrectomy Rat: Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant 14) A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication Seizure activity Rat: Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is an occasional side effect 15. The health care provider (HCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? Withhold the medication and call the HCP, questioning the prescription for the client. Rationale: Exenatide is an incretin mimetic used for type 2 diabetes mellitus only 16) The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data should the nurse include? Select all that apply. hin body build 2. Smoking history 3. Postmenopausal age 4. Chronic corticosteroid use 6. Family history of osteoporosis Rat: A high intake of dairy products is not associated with osteoporosis because dairy products are high in calcium 17. A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate? "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions." Rat: The infectious period of chickenpox is 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and the crusting of the lesions. The remaining options are inaccurate statements. 23) The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? Client with diabetes insipidus 25. The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? Bone pain Rat: Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint 26 The nurse determines the client needs further instruction on cimetidine if which statements were made? Select all that apply. I will take the cimetidine with my meals." 2. "I'll know the medication is working if my diarrhea stops." 3. "My episodes of heartburn will decrease if the medication is effective." 4. "Taking the cimetidine with an antacid will increase its effectiveness." Rat: Cimetidine, a histamine (H2)-receptor antagonist, helps to alleviate the symptom of heartburn, not diarrhea. 27. A young man with type 1 diabetes mellitus tells the nurse that he might lose his job because he has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes and that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? Examine factors with the client that may be causing frequent hypoglycemic episodes. Rat: Hypoglycemic reactions present as adrenergic symptoms of tremor, shakiness, and nervousness that are comparable or alike to the signs of alcohol intoxication 28. The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? Incomplete An incomplete fracture is one that extends through only part of the thickness of the bone. 29 The nurse is providing education to a client who is being started on atenolol. Which statement by the client indicates that teaching has been effective "I am takin