Friday, September 24, 2010

NCLEX practice question 4

1. Which contraindication should the nurse assess for prior to giving a child immunizations?
A) Mild cold symptoms
B) Chronic asthma
C) Depressed immune system
D) Allergy to eggs

The correct answer is C: Depressed immune system
Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations

2.      Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?

A)   Liver function

B)     Kidney function

C)   Blood sugar

D)   Cardiac enzymes

The correct answer is A: Liver function
INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.

3.      Which client is at highest risk for developing a pressure ulcer?

A)   23 year-old in traction for fractured femur

B)     72 year-old with peripheral vascular disease, who is unable to walk without assistance

C)   75 year-old with left sided paresthesia and is incontinent of urine and stool

D)   30 year-old who is comatose following a ruptured aneurysm

The correct answer is C: 75 year-old client with left sided paresthesia and is incontinent of urine and stool
Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

4.      A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially?

A)   Conduct guided imagery or distraction

B)     Ensure that the stump is elevated for the initial day

C)   Wrap the stump snugly in an elastic bandage

D)   Administer opioid narcotics as ordered

The correct answer is B: Ensure that the stump is elevated for the initial day
The priority is to elevate the stump, preventing pressure caused by pooling of blood and thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. The opioid would be given for severe pain.

5.      A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?

A)               Capillary refill of fingers on right hand is 3 seconds

B)                 Skin warm to touch and normally colored

C)               Client reports prickling sensation in the right hand

D)               Slight swelling of fingers of right hand

The correct answer is C: Client reports prickling sensation in the right hand
Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.

6.      What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?

A)               Set good examples themselves

B)                 Protect their child from outside influences

C)               Make sure their child understands all the safety rules

D)               Discuss the consequences of not wearing protective devices

The correct answer is A: Set good examples themselves
Preschool years is the time for parents to begin emphasizing safety education as well as providing protection. Setting a good example themselves is crucial because of the imitative behaviors of pre-schoolers; they are quick to notice discrepancies between what they see and what they are told.

7.      A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?

A)               Check the skin on the sacrum for breakdown

B)                 Inspect the pin site for signs of infection

C)               Auscultate the lungs for atelectasis

D)               Perform a neurovascular check for circulation

The correct answer is D: Perform a neurovascular check for circulation
While each of these is an important assessment, the neurovascular integrity is most associated with this type of traction. Russell’s traction is Buck’s traction with a sling under the knee.

8.      The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

A)               Periorbital edema

B)                 Dizziness spells

C)               Lethargy

D)               Shortness of breath

The correct answer is B: Dizziness spells
Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs of ventricular tachycardia or periods of asystole and should be reported immediately.

9.      A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?

A)               Cardiac rhythm strip

B)                 Pupillary response

C)               Pulse oximetry

D)               Peripheral glucose stick

The correct answer is C: Pulse oximetry
A sudden change in mental status in any post-op client should trigger a nursing intervention directed toward further respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client''s findings, the first nursing action should be directed toward oxygenation issues. Once respiratory or oxygenation issues are ruled out then significant changes in glucose would be next to evaluate

10. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?

A)               Call the health care provider

B)                 Access the site by cutting a window in the cast

C)               Record the findings in the nurse's notes only

D)               Outline the spot with a pencil and note the time and date on the cast

The correct answer is D: Outline the spot with a pencil and note the time and date on the cast
This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse’s notes.

11. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?

A)               “Your child must use a care seat until he weighs at least 40 pounds."

B)                 The child must be 5 years of age to use a regular seat belt.

C)               “Your child must reach a height of 50 inches to sit in a seat belt."

D)               “The child can use a regular seat belt when he can sit still."

The correct answer is A: “Your child must use a care seat until he weighs at least 40 pounds."
A child should use a car seat until they weigh 40 pounds.

13. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?

A)               Days 7-10

B)                 Days 10-13

C)               Days 14-16

D)               Days 17-19

The correct answer is D: Days 17-19
Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days, subtracting 14 from 32 suggests ovulation is at about the 18th day.

14. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

A)               Place the child in the nearest bed

B)                 Administer IV medication to slow down the seizure

C)               Place a padded tongue blade in the child's mouth

D)               Remove the child's toys from the immediate area

The correct answer is D: Remove the child''s toys from the immediate area
Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child''s mouth and they should not be moved. Of the choices given, first priority would be for safety

15. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?

A)               Vary the interview style for each candidate to learn different techniques

B)                 Use simple questions requiring "yes" and "no" answers to gain definitive information

C)               Obtain an interview guide from human resources for consistency in interviewing each candidate

D)               Ask personal information of each applicant to assure meeting of job demands

The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate
An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch

16. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication?

A)               Lowered BMR

B)                 Reduced PaO2

C)               Lethargy

D)               Metabolic alkalosis

The correct answer is B: Reduced PaO2
Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 36 degrees Celsius (97 degrees Fahrenheit).

17. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

A)               Irritability

B)                 Slight edema at site

C)               Local tenderness

D)               Temperature of 102.5 F

The correct answer is D: Temperature of 102.5 F
An adverse reaction of a fever should be reported immediately. Other reactions that should be reported include crying for > 3 hours, seizure activity, and tender, swollen, reddened areas.

18. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remedies

A)               Destroy organisms causing disease

B)                 Maintain fluid balance

C)               Boost the immune system

D)               Increase bodily energy

The correct answer is C: Boost the immune system
The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body''s own defenses

19. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?

A)               Using a moist soft brush or cloth to clean teeth and gums

B)                 Swabbing teeth and gums with flavored mouthwash

C)               Offering a bottle of water for the child to drink

D)               Brushing with toothpaste and flossing each tooth

The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums
The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth

20. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?

A)               "I give my insulin to myself in my thighs."

B)                 "Sometimes when I put my shoes on I don't know where my toes are."

C)               "Here are my up and down glucose readings that I wrote on my calendar."

D)               "If I bathe more than once a week my skin feels too dry."

The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."
Peripheral neuropathy can lead to lack of sensation in the lower extremities. Clients do not feel pressure and/or pain and are at high risk for skin impairment.

21. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?

A)               Protect the eyes of the neonate from the heat lamp

B)                 Monitor the neonate’s temperature

C)               Warm all medications and liquids before giving

D)               Avoid touching the neonate with cold hands

The correct answer is B: Monitor the neonate’s temperature
When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations. The use of heat lamps is not safe as there is no way to regulate their temperature. Warming medications and fluids is not indicated. While touching with cold hands can startle the infant it does not pose a safety risk.

22. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?

A)               Bounding pulse

B)                 Rapid respirations

C)               Oliguria

D)               Neck veins are distended

The correct answer is C: Oliguria
Kidneys maintain fluid volume through adjustments in urine volume.

source: NCSBN


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