NCLEX Trainer Test 3
Question 1 of 5.
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
A. explaining that the client will be walking with a prosthesis soon after surgery.
B. encouraging the client to share his feelings and fears about the surgery.
C. taking the informed consent form to the client and asking him to sign it.
D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Explanation: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
Question 2 of 5.
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
A. Of course, I will do as you wish.
B. I am obligated to try and preserve life.
C. Do you have advance directives? These need to be in your record.
D. Be sure to tell each nurse your desires.
Explanation: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.
Question 3 of 5.
An adult is receiving lithium carbonate 600 mg tid. Which of the following observations is of greatest concern to the nurse?
A. The serum lithium level is 1.0 mEq/L.
B. The client states that she is going to go on a low-sodium diet.
C. The client has gaining 10 lb in the last three months.
D. The client says, 'I always drink a lot of water when I take the pills.'
Explanation: A low-sodium diet increases lithium retention, risking toxicity, a serious concern requiring immediate education or intervention.
Question 4 of 5.
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
A. Persistent diarrhea
B. Frequent vomiting
C. Anxiety attack
D. Emphysema
Explanation: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
Question 5 of 5.
Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
A. Colace is prescribed to make it take longer for blood to clot.
B. Colace makes it easier for the client to relax and reduce stress.
C. Colace helps lower cholesterol levels.
D. Colace reduces straining at stool.
Explanation: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.