NCLEX Trainer Test 8
Question 1 of 5.
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
A. Impaired adjustment
B. Impaired home maintenance
C. Ineffective family therapeutic regimen management
D. Noncompliance
Explanation: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Question 2 of 5.
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
A. Refuse to set up the equipment until a new cord is available
B. Carefully inspect the taped area and set up equipment if it appears intact
C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Explanation: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.
Question 3 of 5.
During a child's 18-month checkup, the mother remarks that her child is not doing any of the following. Which would cause most concern to the nurse?
A. Speaking in full sentences
B. Making eye contact
C. Riding a tricycle
D. Putting together a 24-piece jigsaw puzzle
Explanation: Lack of eye contact at 18 months may indicate developmental issues like autism, warranting urgent evaluation, unlike the other age-appropriate delays.
Question 4 of 5.
The nurse is working in a surgeon's office and talking with a client who is scheduled for surgery in two weeks. The nurse asks about medications and supplements the client may be taking. What medication(s) the client reports would be of most concern to the nurse? Select all that apply.
A. Acetaminophen
B. Ibuprofen
C. Vitamin C
D. Vitamin E
E. Ginseng
F. Vitamin B complex
Explanation: Ibuprofen, Vitamin E, and ginseng increase bleeding risk, posing concerns for surgical hemostasis.
Question 5 of 5.
The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
A. I don't seem to have much of an appetite lately.'
B. My energy level is not as high as it once was.'
C. My pulse yesterday was 60.'
D. I have a pain in my right foot.'
Explanation: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
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