NCLEX Trainer Test 7
Question 1 of 5.
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
Explanation: Perform a neurovascular check for circulation. While each of these is an important assessment, the neurovascular integrity check is most associated with this type of traction. Russell's traction is Buck's traction with a sling under the knee.
Question 2 of 5.
The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
A. Position the infant in the car seat as positioned.
B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
D. Place the car seat in the back seat and position the infant appropriately.
Explanation: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
Question 3 of 5.
A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
A. Say to him, 'There is no one there. Keep your voice down.'
B. Escort the client to his room
C. Restrain the client
D. Offer PRN haloperidol (Haldol) as ordered
Explanation: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.
Question 4 of 5.
The nurse is providing home care to an 89-year-old man. Which comments by the client indicate a need for further follow up? Select all that apply.
A. Excuse me if my socks don't match. I can't tell blue from green anymore.
B. Please don't open the blinds. It hurts my eyes when the sun is bright.
C. Let me get my reading glasses so I can read that pamphlet.
D. I don't hear so well, but I don't want a hearing aid. I'm too old to spend that kind of money on myself.
E. Sometimes I have to check the calendar to be sure what day it is.
F. My grandchildren call me 'old slowpoke' because I walk slower than they do.
Explanation: Color vision loss, photophobia, hearing loss, and memory issues suggest potential medical issues (e.g., cataracts, glaucoma, hearing impairment, cognitive decline) requiring follow-up.
Question 5 of 5.
The nurse is caring for an adult who is admitted in right heart failure. Which observation is most consistent with this condition?
A. Distended neck veins
B. Facial edema
C. Renal failure
D. Constipation
Explanation: Right heart failure causes systemic venous congestion, leading to distended neck veins due to increased jugular venous pressure. Facial edema, renal failure, and constipation are less specific to right heart failure.
Related Questions
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