NCLEX Kaplan #2 – Flashcards

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question
The nurse finds a visitor slumped to the floor of a patient's room during visiting hours at the hospital. INITIALLY, the nurse should take which of the following actions? 1. Start rescue breathing and chest compressions. 2. Call for help. 3. Shake the patient and shout, "Are you all right?" 4. Listen for breath sounds.
answer
Strategy: Remember the nursing process. 1) implementation; need to assess first 2) implementation; need to assess first 3) CORRECT— assess unconsciousness; open airway with head tilt of chin lift (jaw thrust if neck injury is suspected); look, listen, and feel for signs of breathing 4) assessment, but should not be done first
question
The home care nurse returns to the office to find four phone messages. Which of the following messages should the nurse return FIRST? 1. The daughter of a client diagnosed with lung cancer states that her father refuses chemotherapy today. 2. A client is asking when staples can be removed from his abdominal incision. 3. A client with a colostomy complains that the skin is raw around the stoma. 4. The wife of a client with a cerebrovascular accident states that her husband is refusing a bath.
answer
trategy: Determine the most unstable client. 1) CORRECT— assess whether client is experiencing side effects 2) should ask client if incision is red or if there is any drainage 3) second call to be returned; ensure that skin sealant does not contain alcohol and instruct client to use stoma powder or paste 4) stable client
question
The 35-year-old mother of five children ranging in age from 4 to 17 years tells the health service nurse, "The father of my children passed away 3 weeks ago. We had been apart for several years, but the children have taken his death really badly." When asked how she herself has handled the death, she replies, "I am doing OK. I have been focused on helping the children. I can hardly believe it happened. He was only 34 years old. I don't know if and when it will really hit and upset me that he is gone." Which of the following responses by the nurse is MOST appropriate initially? 1. "Did he use drugs? It is known that some can cause a heart attack in someone so young." 2. "It may not. But you may be in the first stage of grieving, which is shock and denial." 3. "You certainly have your hands full right now, and you're doing a wonderful job." 4. "How helpful was he to you in raising and supporting the children?"
answer
Strategy: Remember therapeutic communication. (1.) not best; accurate information, especially for cocaine; may help the mother understand what occurred; however, the question is closed-ended and the whole response is factually oriented, versus encouraging expression (2.) CORRECT—responds directly to mother's statement and focuses on her: provides factual information and the beginning of a framework to understand what she is probably going through (3.) does not respond directly to mother's last statement or encourage discussion; does convey recognition of extent of her current responsibilities (4.) not best initially, elicits important factual and subjective information that could be used to assess the mother's changed current and future parenting burden and to begin planning for any needed family, community, or other assistance; does not respond to mother's last statement
question
The pediatric clinic nurse conducts a parent education class related to disciplinary measures for young children. It is MOST important for the nurse to emphasize which of the following points? 1. Explain to the child why an act is wrong, especially if it relates to moral issues. 2. A good rule of thumb for time-outs is 1 minute for each year of the child's age. 3. If a child cries and refuses a time-out, add another time-out period to the initial one. 4. Once the child has calmed down after disciplinary measures, review what occurred.
answer
Strategy: Determine the outcome of each answer. Is it desired? (1.) younger children are egocentric and, being in the preoperational cognitive developmental stage of thinking, are limited in ability to see the difference between their own point of view and the points of view of others (2.) CORRECT—1 minute for each year of the child's age is the recommended practice for time-outs; for toddlers, conception of time is limited and 1 minute can seem like hours; for preschoolers, time is still not fully understood and is interpreted within their own frame of reference; a kitchen timer with an audible bell can be useful so the child knows, and the parent does not forget, when the time-out is over (3.) if disruptive behavior such as crying or refusal is shown when a time-out is to begin, the start of the time-out is delayed until the child becomes quiet; explain to the child in advance (4.) once the child has experienced the consequences of his/her actions, the parent should not comment upon that situation because the tendency is for the child to try to blame the parent for imposing the rule
question
The home health nurse assists client to plan for cataract surgery. Which of the following recommendations by the nurse is BEST? 1. "Ask someone to do the vacuuming for a few weeks after the surgery." 2. "Eat foods high in antioxidants." 3. "Stock loperamide (Imodium) 2 mg in the medicine cabinet." 4. "Ask someone to sit with you while waiting for the surgery."
answer
Strategy: Determine the outcome of each answer. Is it appropriate? 1) CORRECT— jerky movements and bending from the waist can increase intraocular pressure 2) may have a protective function against age-related macular degeneration; does not affect cataracts 3) antidiarrheal; diarrhea is not a usual outcome of cataract surgery nor is it a risk; instruct client to avoid straining with bowel movements 4) may require help after the surgery
question
The nurse supervises care for a patient on the hospice unit who practices orthodox Judaism. The nurse determines care is appropriate if which of the following is observed? 1. An unleavened wafer is placed on the tongue of the patient. 2. The patient has a continuous intravenous morphine infusion. 3. The patient is turned to face east as signs of death appear. 4. The patient's forehead is anointed with oil.
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Strategy: "Care is appropriate" indicates correct nursing actions. (1.) wafer known as the Eucharist is offered to Roman Catholic patients and may be given by lay persons; not appropriate for an orthodox Jewish patient (2.) CORRECT—control of pain (palliative treatment) during end of life is most important to Jewish persons (3.) end of life care in the Islam religion requires the dying to face east towards Mecca (4.) anointing with oil is performed in many Christian religions
question
Which of the following findings during a newborn examination requires IMMEDIATE action by the nurse? 1. The left side of the newborn's face is drooping. 2. The newborn's uvula has two lobes. 3. The newborn's ears are low-set bilaterally. 4. The red reflex is absent in the newborn's right eye.
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Strategy: "IMMEDIATE action" indicates priority. (1. ) may indicate facial paralysis from damage to cranial nerve VII (facial nerve) which occurred during delivery; paralysis usually resolves within a few days to 3 weeks, can be permanent. (2.) indicates there may be a cleft in the palate; further assessment of sucking ability and/or hard and soft palate size, shape, and cleft formations should be made (3.) indication that Down's syndrome may be present; further assessment findings which could confirm this include flat occiput, broad nasal bridges, eyes that have epicanthal folds and slant upward, large tongue, high palate, small chin (4.) CORRECT—indicates an ophthalmic emergency because light is not being transmitted to the retina, and the early suppression of optic nerve function which results from the obstruction of the light can cause blindness; notify the physician immediately
question
The nurse in the outpatient clinic cares for a client diagnosed with peptic ulcer disease (PUD) and gout. Which of the following orders, if written by the physician, should the nurse question? 1. "Colchicine (Colsalide) 1 mg q 2 hours until cumulative dose of 8 mg achieved." 2. "Allopurinol (Aloprim) 100 mg daily." 3. "Probenecid (Benemid) 250 mg BID." 4. "Indomethacin (Indocin) 50 mg QID."
answer
Strategy: Think about the side effects of each drug. 1) appropriate order; drug given to treat acute attack of gout 2) appropriate order; inhibits production of uric acid 3) appropriate order; prevents the reoccurrence of gouty arthritis 4) CORRECT— nonsteroidal anti-inflammatory; use cautiously in clients with peptic ulcer disease
question
The nurse determines that which of the following clients are at risk to develop pneumonia? Select all that apply: 1. 16-year-old male who has experimented with cigarettes. 2. A 25-year-old female diagnosed with cystic fibrosis. 3. A 36-year-old male diagnosed with Addison's disease. 4. A 47-year-old male diagnosed with hypertension. 5. A 68-year-old with a fractured rib due to an auto accident. 6. A 79-year-old female in Buck's traction due to a fractured hip.
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Strategy: Think about each answer. 1) habitual cigarette smoking is a risk factor for pneumonia 2) CORRECT— underlying lung disease is a risk factor; CF causes chronic obstructive pulmonary disease and pancreatic exocrine deficiency 3) hyposecretion of adrenal hormones; not a risk factor 4) not a risk factor 5) CORRECT— pain of fractured rib causes shallow breathing pattern 6) CORRECT— due to physiological changes, clients of advanced age are at risk to develop pneumonia; bedrest decreases lung expansion
question
The nurse instructs the mother of a toddler about appropriate foods for her 2-year-old child. It is MOST important for the nurse to make which of the following suggestions? 1. Provide the child with finger foods. 2. Allow the child to eat favorite foods. 3. Encourage a diet high in protein. 4. Limit the number of snacks offered to the child.
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Strategy: Topic of question is unstated. 1) CORRECT— toddler is working to develop autonomy; finger foods offer the child the necessary independence for this stage 2) parents' responsibility to offer a variety of nutritionally sound foods 3) needs carbohydrates for energy 4) toddlers eat small amounts of food; offer nutritionally sound snacks
question
The nursing staff at the new pediatric hospital discusses instituting a community education program regarding mental retardation, particularly prevention. It is MOST beneficial for the nurses to emphasize which of the following areas? 1. Alcoholism treatment. 2. Phenylketonuria (PKU) screening. 3. Nutritional supplementation. 4. Prenatal classes.
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Strategy: "MOST beneficial" indicates that discrimination is required to answer the question. (1.) CORRECT—alcohol is recognized as the leading cause of preventable mental retardation; mental retardation is included in the fetal alcohol syndrome (FAS) complex of symptoms (2.) very important, but not priority; screening for PKU occurs in newborns (3.) important, but not best (4.) timing is close to the birth; tendencies toward mental retardation have already been established
question
An 89-year-old man with Alzheimer's disease wanders around the unit disturbing other patients. Which of the following actions by the nurse would be MOST appropriate? 1. Call the physician for an order for a tranquilizer. 2. Place the patient in a geri chair with a clipboard to complete a puzzle. 3. Allow the patient to assist the staff to sort the linen. 4. Explain to the patient that he may not leave his room.
answer
Strategy: Determine the outcome of each answer. Is it desired? 1) "passing the buck" and a premature action; use least restrictive measures 2) patient will be unable to complete puzzle due to cognitive dysfunction; will increase confusion and possibly combativeness; form of restraint 3) CORRECT— keeps patient active and independent, structures his environment, promotes socialization, orients him and preserves his dignity; does not block his wandering behaviors but uses them constructively; it also protects others from intrusion 4) the patient may be unable to understand and/or control his behavior; provide calm, predictable environment with regular routine; give clear and simple explanations
question
The nurse cares for clients in the outpatient clinic during an outbreak of the flu. The nurse notes many family members accompanied clients to the clinic. Several of the family members appear to have a dry cough and runny noses. Which of the following actions should the nurse take FIRST? 1. Inform the family members they should stay home if they have a cough. 2. Instruct the coughing family members to sit at least 3 feet way from others. 3. Post an alert at the entrance to the facility. 4. Provide tissues to the family members.
answer
Strategy: "FIRST" indicates priority. 1) should not go out if infected with flu; since visitors with flu symptoms are in the waiting room, priority is to prevent spread of the flu 2) CORRECT— influenza spread by droplets; nurse should offer masks to people who are coughing, as well as enforce separation 3) appropriate action during periods of heightened flu activity; more important to protect clients and family members in the waiting room 4) appropriate action; priority is separating the symptomatic individuals from the asymptomatic individuals
question
The nurse administers meperidine (Demerol) 50 mg IV for pain to a client in labor. Which of the following fetal heart rate (FHR) patterns should the nurse anticipate as a result of administering this medication? 1. Early decelerations. 2. Late decelerations. 3. Variable decelerations. 4. Decreased variability.
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Strategy: Think about the action of Demerol. 1) occur before the peak of the contraction; result from fetal head compression 2) occur after the peak of the contraction; result from uteroplacental insufficiency 3) occur any time during uterine contraction; result from cord compression 4) CORRECT— irregular fluctuations in the baseline of FHR; Demerol crosses the placenta and is a CNS depressant; FHR variability is affected by narcotic administration
question
The mother of a 13-year-old boy confides to the nurse in the pediatrician's office that she is concerned because her son has recently become clumsy and uncoordinated. Which of the following responses by the nurse is BEST? 1. "Your son might have attention deficit hyperactivity disorder." 2. "I'll talk with the pediatrician about assessing for subtle motor dysfunction. " 3. "Your son's clumsiness is expected at this age." 4. "This may be an early sign of depression."
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Strategy: Answers are quotes by the nurse. Think about what the words mean. 1) disorder indicated by inattention, hyperactivity, impulsivity; children demonstrate low frustration level, intolerance for changes in environment, and failure to respond to discipline; clumsiness and incoordination are not indications of ADHD 2) insufficient data provided to draw this conclusion 3) CORRECT— initial problems with coordination; appearance of clumsiness related to rapid, unsynchronized growth of many systems; growth is linear; outgrow shoes, then pants, and then shirts 4) indications include declining school grades, chronic melancholy, family dysfunction, alcohol or other drug use, suicide attempts
question
The nurse performs a physical assessment of a newborn. It is MOST important for the nurse to report which of the following findings? 1. Head circumference of 40 cm. 2. Chest circumference of 32 cm. 3. Acrocyanosis and edema of the scalp. 4. Heart rate of 160 bpm and respirations of 40/min.
answer
Strategy: "MOST important" indicates discrimination may be required to answer the question. 1) CORRECT— average head circumference is 33-35 cm; increased size may indicate hydrocephaly or increased intracranial pressure 2) normal finding; chest is usually 1 inch less than head circumference (30.5-33 cm) 3) normal finding 4) within normal limits; heart rate ranges from 120 (sleeping) to 180 (crying); respirations range from 30-60 breaths/min
question
A home health nurse makes an initial visit to a client diagnosed as legally blind. Which of the following recommendations should the nurse make FIRST? 1. Call a plumber to set the hot-water tank's thermostat at 100 degrees. 2. Use battery-operated appliances rather than electrical appliances. 3. Remove most of the furniture from the home 4. Purchase clothing that is easy for the client to don.
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Strategy: "FIRST" indicates priority. 1) CORRECT— reduces possibility of burns by hot water 2) can be taught to use electrical appliances safely 3) no reason to remove furniture; articles and furniture should be kept in the same positions so that client knows where they are 4) client can learn to dress self; does not necessarily require special clothing
question
Which of the following skin manifestations in an infant MOST concerns the nurse? 1. Irregularly shaped pink patches on the back of the neck. 2. Diffuse bluish-purple, bruised-looking areas on the buttocks. 3. Large, irregular, flat macular patch on one side of the face. 4. Red, raised, rough-surfaced, clearly delineated nodules.
answer
Strategy: Think about each answer. (1.) telangiectatic nevi or "stork bites"; may be pink or red and are often on the nape of the neck (the lower occipital bone) and/or on the eyelids, between the eyebrows, on the nose or upper lip; fade as the infant gets older (2.) Mongolian spots; may be bluish-black or gray-blue or purple; may be mistaken as bruises and should be documented in the chart, as should all birthmarks; usually appear in sacral and/or gluteal area, back, shoulders; common in newborns of African, Asian, Native American, or Hispanic descent; gradually fade during first or second year of life (3.) CORRECT—this is a nevus flammeus (port wine stain); its color ranges from pink to red to purple and it may appear purple-black in Africans; grows proportionately as the child grows; does not fade; a laser pulse device is used to significantly lighten or completely clear the stain when the child is older (4.) strawberry hemangiomas; benign cutaneous capillary tumors which gradually disappear, usually by the first year of life
question
The nurse determines that a client brought in to the urgent care center may be in shock. It is MOST important for the nurse to place the client in which position? 1. Trendelenburg position. 2. Elevate the head of the bed 45°. 3. On the left side. 4. Elevate the lower extremities.
answer
Strategy: "MOST important" indicates discrimination is required to answer the question. 1) pressure on the thoracic cavity by the abdominal organs increases cardiac workload and respiratory effort 2) impairs circulation to the brain and other vital organs and increases cardiac workload 3) position to prevent aspiration 4) CORRECT— improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort
question
The nurse cares for a client diagnosed with croup. The nurse should follow which of the following transmission-based precautions? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.
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Strategy: Think about each answer. 1) barrier precautions used for all clients to prevent nosocomial infections 2) used with pathogens transmitted by airborne route 3) used with pathogens transmitted by infectious droplets 4) CORRECT— acute viral disease of childhood that causes a resonant barking; contact precautions required for all client care activities that require physical skin to-skin contact or those that require contact with soiled items in the room or linens.
question
The nurse determines that which client is MOST likely to need vitamin B6 (pyridoxine) supplementation? 1. A client diagnosed with tuberculosis. 2. A client diagnosed with pernicious anemia. 3. A client diagnosed with chronic alcoholism. 4. A client at 12 weeks' gestation.
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Strategy: Think about each answer. (1.) CORRECT—client is likely to be taking isoniazid (INH); INH is a mainstay in prevention and treatment of tuberculosis, used in combination with other antitubercular drugs if the disease is active; vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug (2.) needs supplementation with vitamin B12 (3.) needs supplementation with all B vitamins, especially thiamine (vitamin B1); thiamine deficiency is the primary cause of alcohol-related changes such as Wernicke's encephalopathy and Korsakoff's syndrome (4.) needs supplementation with folic acid (vitamin B9) to prevent neural tube defects in the fetus; supplementation is recommended for all women capable of becoming pregnant
question
The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which of the following statements is BEST for the nurse to make to the parents at this time? 1. "You should focus on your baby's personality, not appearance." 2. "Let me show you pictures of some babies before and after surgery." 3. "There are other problems with this condition that go beyond surgical correction." 4. "Has anyone else in either of your families had cleft lip or palate?"
answer
Strategy: Determine the outcome of each answer. Is it desired? (1.) commanding in nature, and judgmental; does not allow for parents' expression of feelings and concerns; facial anomalies in a child are very visible and a severe shock to the parents when first seen (2.) CORRECT—addresses the immediate fears and concerns of the parents, who are in a state of crisis; offers concrete pictorial evidence of a brighter future for their child than they might otherwise have expected (3.) is a true statement, but could be frightening and discouraging to the parents at this time, particularly without having given them the reassurance that surgery can help deal with their immediate concern, the cosmetic situation (4.) genetic factors might be etiologic factor; family history of a cleft increases the risk of other children having a cleft; however, this is a history-taking question, information-based and not helpful at this point
question
The nurse obtains a history from a client scheduled for a permanent pacemaker insertion. It is MOST important for the nurse to convey which information to the physician? 1. The client is diagnosed with obsessive-compulsive disorder. 2. The client wears a hearing aid in the left ear. 3. The client works as a computer programmer. 4. The client lives in a two-story house.
answer
Strategy: "MOST important" indicates discrimination is required to answer the question. 1) not most important; may impact teaching about pacemaker management, specific directions likely to be followed, especially if written, but anxieties about pacemaker function and safety may be intense 2) CORRECT— hearing aid battery may affect placement of pacemaker; should not be placed under the left clavicle in this client 3) equipment that is grounded and well maintained is not a problem 4) clients with pacemakers do not require stair-climbing restrictions unless heart rhythm shows marked variation in response to this activity
question
The nurse counsels a client newly diagnosed with hypertension. Which of the following statements, if made by the client to the nurse, indicates that teaching is successful? 1. "If I feel dizzy when I wake up, I will skip my morning blood-pressure pill." 2. "I will switch from lifting weights at the health club to doing aerobics." 3. "I will be sure to take chlorothiazide (Diuril) every night before I go to bed." 4. "I will take hot baths or go to the sauna to relax if I feel tension coming on."
answer
Strategy: "Teaching is successful" indicates correct information. (1.) medication needs to be taken on a regular basis; instruct to rise slowly from lying and sitting positions; if severely bothered by dizziness, contact physician (2.) CORRECT—regular aerobic exercises are usually recommended; isometric exercises such as heavy weight-lifting and rowing are contraindicated, can cause a dangerous rise in blood pressure due to a vasovagal response during intense isometric muscle contraction (3.) thiazide diuretic; nighttime dosing will interfere with sleep by requiring frequent urination (4.) not best; antihypertensives (and diuretics) commonly cause hypotension and heat can facilitate hypotension
question
The nurse cares for a client diagnosed with lung cancer. The client has gained 2 kg since yesterday and lab values reveal sodium 122 mEq/L and potassium 4.5 mEq/L. The nurse anticipates that the physician will order which of the following? 1. Desmopressin DDAVP (Vasopressin). 2. Furosemide (Lasix) 40 mg IV push. 3. Sodium polystyrene sulfonate (Kayexalate). 4. IV of normal saline to run at 125 mL/h.
answer
Strategy: Topic of question is unstated. 1) given for diabetes insipidus 2) CORRECT— lung cancer is a common cause of SIADH, which is abnormal secretion of ADH; results in increased water absorption and dilutional hyponatremia; diuretics used to promote fluid loss 3) given to treat hyperkalemia; normal potassium is 3.5 to 5.0 mEq/L 4) fluids restricted for SIADH
question
A 1-month-old infant is brought to the pediatrician's office. Which of the following findings, if observed by the nurse, warrants further investigation? 1. The anterior fontanel becomes taut when the infant cries. 2. The infant has head lag when pulled from a lying to a sitting position. 3. The top of the infant's right knee is 1 inch higher than the left knee. 4. The infant extends his left arm and leg when his head is turned to the left.
answer
Strategy: "warrants further investigation" indicates something is wrong. 1) expected; ceases at 18 months 2) expected behavior 3) CORRECT— suggestive of developmental dysplasia of the hip; other symptoms include asymmetry of the gluteal and thigh folds 4) expected behavior; asymmetric tonic neck reflex
question
The nurse in the neurological unit admits an adolescent who was struck in the right temple with a blunt object. It is MOST important for the nurse to observe for which of the following? 1. Diarrhea. 2. Slowing of speech. 3. Nausea and vomiting. 4. Vertigo and insomnia.
answer
Strategy: "MOST important" indicates discrimination may be required to answer the question. 1) if client has a head injury, important to assess for ICP; diarrhea is not an indication of ICP 2) CORRECT— early indicator of ICP; other indications are changes in LOC, restlessness, and confusion 3) may see pupillary changes, increased BP, decreased pulse 4) any signs/symptoms of changes in nervous system should be reported, but slowing of speech is early indicator of ICP
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