Nclex-Rn Practice Questions-Appendices And İndex - Comprehensive Test 5 Part 2
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Question 1 |
A client with long-standing rheumatoid arthritis has frequent complaints of joint pain. The nurse’s plan of treatment is based on the understanding that chronic pain is most effectively relieved when analgesics are administered in which way?
A | Conservatively |
B | Intramuscular (I.M.) alternating with intravenous (I.V.) |
C | On an as-needed basis |
D | At regularly scheduled intervals |
Question 2 |
A client receiving phenothiazine has become restless and fidgety and has been pacing the hallway continuously for the past hour. This behavior suggests to the nurse that the client may be experiencing which adverse reaction to phenothiazine?
A | Dystonia |
B | Akathisia |
C | Parkinsonian effects |
D | Tardive dyskinesia |
Question 3 |
Which goal will the nurse make the highest priority in a client with a new tracheostomy?
A | Developing an effective means of communication |
B | Maintaining a patent airway |
C | Preventing infection |
D | Gaining independence in self-care |
Question 4 |
A registered nurse is in charge of eight clients. The nurse has a licensed practical nurse (LPN) and a client care assistant working under her. Which activity should the nurse assign to herself rather than delegate to the staff?
A | Consoling a grieving visitor |
B | Assessing a newly admitted client |
C | Irrigating a Salem sump to continuous drainage |
D | Giving a tap water enema to a preoperative client |
Question 5 |
Parents of a toddler are having problems putting him to bed at night. Which recommendation by a nurse is most appropriate?
A | Stop the afternoon naps. |
B | Allow the toddler to have a tantrum for ½ hour. |
C | Encourage the parents to develop nighttime rituals. |
D | Allow the toddler to have some control over bedtime. |
Question 6 |
After abdominal surgery for repair of an aortic aneurysm, a client may show maladaptive coping behavior in response to body changes related to the surgery. Which nursing intervention is best?
A | Let the client express his feelings. |
B | Explain that a psychological referral would be beneficial. |
C | Instruct the client on how to use positive coping strategies. |
D | Encourage the client to participate in diversionary activities. |
Question 7 |
A new graduate nurse has started at the medical center and is assigned to a preceptor. The preceptor and other staff report that the nurse is uncooperative and unwilling to take direction. Which action by the preceptor is appropriate?
A | Explain the behavior won’t be tolerated. |
B | Ask the nurse why she wants to work here. |
C | Reestablish goals with the nurse. |
D | Begin the disciplinary process with this nurse. |
Question 8 |
A client with a history of bipolar disorder rushes into the mental health clinic waiting room scantily dressed and makes loud, obscene remarks to other clients. Which intervention by the nurse is most appropriate?
A | Encourage the other clients to ignore the behavior. |
B | Confront the behavior and make the client take a seat. |
C | Tell the client to sit down and stop upsetting the others. |
D | Quietly escort the client to a private area and help put on a gown. |
Question 9 |
A registered nurse (RN) is supervising an unlicensed care provider. Which principle would the nurse follow when delegating tasks?
A | The RN must directly supervise all delegated tasks. |
B | After a task is delegated, it’s no longer the RN’s responsibility. |
C | The RN is responsible for delegating tasks to adjunct personnel. |
D | Follow-up with a delegated task is necessary only if the assistive personnel are untrustworthy. |
Question 10 |
An elderly client had recent surgery and is on bed rest. When planning care for the client, which nursing intervention is included in the care plan?
A | Daily assessment of the wound site |
B | Foot and ankle range-of-motion (ROM) exercises |
C | Wound cleaning with hydrogen peroxide |
D | Coughing and deep breathing in the prone position |
Question 11 |
Which nursing discharge instruction has the highest priority for a client going home with a full leg cast?
A | Activity restrictions |
B | Proper nutrition |
C | Weight-bearing limitations |
D | Reporting signs of impaired circulation |
Question 12 |
A nurse notes crackles in the lung bases and pedal edema during a client assessment. Which factor is a common cause of fluid volume excess?
A | Prolonged fever |
B | Hyperventilation |
C | Excessive I.V. infusion |
D | Fluid volume shifts secondary to vomiting |
Question 13 |
A client is given instructions for a low-sodium diet. Which statement best shows the nurse that the client understands the diet instruction?
A | “Meat, fish, and chicken are high in sodium.” |
B | “I’ll miss eating fruits.” |
C | “I’ll enjoy eating at restaurants more often now.” |
D | “I’ll avoid dairy products, potato chips, and carrots.” |
Question 14 |
A client must choose a meal that follows his diet orders of a high-calorie, high-protein, low-sodium, and low-potassium diet. Which choice indicates to the nurse that the client understands the dietary guidelines?
A | Halibut, salad, rice, and instant coffee |
B | Crab, beets, spinach, and baked potato |
C | Salmon, rice, green beans, sourdough bread, coffee, and ice cream |
D | Sirloin steak, salad, baked potato with butter, and chocolate ice cream |
Question 15 |
A client with terminal cancer tells the nurse, “I’ve given up. I have no hope left. I’m ready to die.” What is the most appropriate response by the nurse?
A | “You’ve given up hope?” |
B | “You should talk about dying to a social worker.” |
C | “You should talk to your physician about your fears of dying.” |
D | “You shouldn’t give up hope. There are cures for cancer found every day.” |
Question 16 |
The nurse is performing an admission assessment. What is the best statement/question for the nurse to use to gather the most information about the reason for admission would be?
A | “Does your abdomen have sharp pains?” |
B | “Are you noticing more gas with this condition?” |
C | “Tell me how things have been going for you.” |
D | “I’d like to further question your pain.” |
Question 17 |
The nurse can administer which mediation through a nasogastric (NG) tube?
A | Enteric-coated aspirin |
B | Acetaminophen |
C | Regular insulin |
D | Sublingual nitroglycerine |
Question 18 |
A client who was recently hospitalized has a nursing diagnosis of constipation related to medical regimen. Which medication may contribute to this problem?
A | Folic acid |
B | Iron |
C | Potassium |
D | Vitamin E |
Question 19 |
The nurse knows that if a client requires oxygen delivery at a FIO2 of 92%, the appropriate system would be a:
A | face tent. |
B | Venturi mask. |
C | nasal cannula. |
D | mask with reservoir bag. |
Question 20 |
A client is 2 days postoperative from a femoral popliteal bypass. The nurse’s assessment finds the client’s left leg cold and pale. What is the most important action by the nurse?
A | Check distal pulses. |
B | Notify the physician. |
C | Elevate the foot of the bed. |
D | Wrap the leg in a warm blanket. |
Question 21 |
A client who had his gallbladder removed 2 days ago now complains of pain in the right calf. Which nursing response has priority?
A | Assess the leg for swelling and redness. |
B | Instruct the client to flex his knee and hip. |
C | Apply a warm compress and call the physician. |
D | Gently massage the calf and notify the physician. |
Question 22 |
A 6-year-old client needs diabetic teaching. Which factor is considered when the nurse plans the teaching?
A | Another child with diabetes can teach the client. |
B | The child can teach his parents after the nurse teaches him. |
C | The child and parents should be recipients of teaching. |
D | Teaching should be directed to the parents, who then can teach the child. |
Question 23 |
The client has returned from the operating room with the nursing diagnosis of acute pain. The nurse knows the best means of providing comfort would be to administer:
A | morphine sulfate 10 mg intramuscularly. |
B | morphine sulfate 0.2 mg/ml via patient-controlled analgesia. |
C | Dilaudid 2 mg I.V. every 2 hours. |
D | Percocet 5 mg orally every 4 to 6 hours. |
Question 24 |
A client had an appendectomy 24 hours ago. Which nursing goal is appropriate for this client?
A | The client will be able to walk in the hallway. |
B | The client will be able to attend physical therapy. |
C | The client will be able to accomplish all activities of daily living. |
D | The client will be able to state the rationale for all postoperative medications. |
Question 25 |
Which instruction should a nurse include in the teaching plan for a client with a platelet count of 25,000/mm3 and petechial rash on the legs, arms, and neck?
A | Take an iron supplement daily. |
B | Take acetaminophen rather than aspirin for headache. |
C | Stay away from crowds during the flu season. |
D | Avoid fresh salads. |
Question 26 |
Which statement is an example of a key element in the nursing care plan?
A | Advance diet to regular as tolerated. |
B | Ambulate 30′ (9 m) with walker by discharge. |
C | Give furosemide (Lasix) 40 mg I.V. now. |
D | Discontinue I.V. fluids when tolerating oral fluids. |
Question 27 |
A client with difficulty breathing has a respiratory rate of 34 breaths/minute and demonstrates anxious behaviors. He’s refusing all his medications, claiming they’re making him worse. Which nursing action is best?
A | Notify the physician of the status of this client. |
B | Withhold the medication until the next scheduled dose. |
C | Encourage the client to take some of his medications. |
D | Put the medicine in applesauce to give it without the client’s knowledge. |
Question 28 |
Which statement by a client with chronic arterial disease indicates to the nurse further teaching is needed?
A | “I’m going to stop smoking.” |
B | “I’m going to have the podiatrist check my feet.” |
C | “I’m going to keep the heat in my house at 80° F.” |
D | “I’m going to walk short distances every morning.” |
Question 29 |
To prevent aspiration in a client with impaired swallowing, the nurse should:
A | provide a straw for drinking liquids. |
B | remove dentures before eating. |
C | position the client at a 90-degree angle. |
D | place food on the paralyzed side of the mouth. |
Question 30 |
Which laboratory value for a newly diagnosed client with diabetes should the nurse report to the physician?
A | pH, 7.45 |
B | Sodium, 118 mEq/L |
C | Glucose, 120 mg/dl |
D | Potassium, 3.9 mEq/L |
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