NCLEX Trainer Test 10

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Question 1 of 5.

Which of the following nursing actions should take priority during the working stage of their relationship?

A. Observe the client every half-hour to determine the extent of drug-seeking behavior.

B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.

C. Help the client obtain a sponsor through a 12-step group in the client's local area.

D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.

Explanation: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems

Question 2 of 5.

The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?

A. I'll remind the patient to use the bedpan instead of the bathroom toilet.

B. I'll use a tongue blade to collect a small amount of stool in a clean container.

C. I'll get a couple of specimens this afternoon because the patient is having loose stools.

D. I'll ask the patient if he has ingested any red meat recently.

Explanation: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading

Question 3 of 5.

Which of the following action should the nurse take FIRST?

A. Determine what other medications the patient is taking.

B. Perform a neurological assessment.

C. Administer haloperidol decanoate (Haldol D) IM stat.

D. Administer the PRN trihexyphenidyl (Artane) IM immediately.

Explanation: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane

Question 4 of 5.

Which of the following patients should the nurse see FIRST?

A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.

B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.

C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.

D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.

Explanation: Strategy: Think ABCs. (1) does not indicate acute bleeding, small amount of blood (2) expected outcome (3) indicates resolution (4) correct-risk for peritonitis, should be assessed for further symptoms of infection

Question 5 of 5.

It would be MOST important for the nurse to take which of the following actions?

A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.

B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.

C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.

D. Start an IV line and piggyback the Pitocin with an infusion pump.

Explanation: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump

Question 1 of 5.

Which of the following nursing actions should take priority during the working stage of their relationship?

A. Observe the client every half-hour to determine the extent of drug-seeking behavior.

B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.

C. Help the client obtain a sponsor through a 12-step group in the client's local area.

D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.

Question 2 of 5.

The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?

A. I'll remind the patient to use the bedpan instead of the bathroom toilet.

B. I'll use a tongue blade to collect a small amount of stool in a clean container.

C. I'll get a couple of specimens this afternoon because the patient is having loose stools.

D. I'll ask the patient if he has ingested any red meat recently.

Question 3 of 5.

Which of the following action should the nurse take FIRST?

A. Determine what other medications the patient is taking.

B. Perform a neurological assessment.

C. Administer haloperidol decanoate (Haldol D) IM stat.

D. Administer the PRN trihexyphenidyl (Artane) IM immediately.

Question 4 of 5.

Which of the following patients should the nurse see FIRST?

A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.

B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.

C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.

D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.

Question 5 of 5.

It would be MOST important for the nurse to take which of the following actions?

A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.

B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.

C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.

D. Start an IV line and piggyback the Pitocin with an infusion pump.

Question 1 of 5.

Which of the following nursing actions should take priority during the working stage of their relationship?

A. Observe the client every half-hour to determine the extent of drug-seeking behavior.

B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.

C. Help the client obtain a sponsor through a 12-step group in the client's local area.

D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.

Question 2 of 5.

The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?

A. I'll remind the patient to use the bedpan instead of the bathroom toilet.

B. I'll use a tongue blade to collect a small amount of stool in a clean container.

C. I'll get a couple of specimens this afternoon because the patient is having loose stools.

D. I'll ask the patient if he has ingested any red meat recently.

Question 3 of 5.

Which of the following action should the nurse take FIRST?

A. Determine what other medications the patient is taking.

B. Perform a neurological assessment.

C. Administer haloperidol decanoate (Haldol D) IM stat.

D. Administer the PRN trihexyphenidyl (Artane) IM immediately.

Question 4 of 5.

Which of the following patients should the nurse see FIRST?

A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.

B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.

C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.

D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.

Question 5 of 5.

It would be MOST important for the nurse to take which of the following actions?

A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.

B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.

C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.

D. Start an IV line and piggyback the Pitocin with an infusion pump.

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