NCLEX Trainer Test 5
Question 1 of 5.
Extract:A nursing assistant states that her five-year-old child has developed chickenpox.
It would be MOST important for the nurse to ask which of the following questions?
A. Have your other children had chickenpox?'
B. Does your child have a temperature?'
C. Have you had the chickenpox?'
D. Do you have someone to watch your child?'
Explanation: Strategy: 'MOST important' indicates there may be more than one answer that you would like to select. Remember, you can only ask one question. (1) chickenpox spread by direct contact, airborne route; not the most important question (2) fever, malaise, and anorexia occur during first 24 hours; treat with Tylenol (3) correct-need to ascertain if staff has had the disease; if not, VZIG can be given; exclude from patient care from the 10th day after first exposure through the 21st day (28th day if VZIG given) after last exposure (4) important information, but assessing staff is most important
Question 2 of 5.
A 16-year-old client is admitted for elective surgery. The LPN is asked to have the child's mother sign the operative permit. Which action by the nurse is most appropriate?
A. Have the parent sign the permit form
B. Refuse to ask the parent to sign the permit form
C. Ask the unit secretary to have the parent sign the permit form
D. Have both the child and the parent sign the permit form
Explanation: For minors, a parent or guardian must sign the operative permit, as they provide legal consent for the procedure.
Question 3 of 5.
A 3-year-old child who is up to date with all immunizations is seen at clinic. The child has a fever of 102°F and a pruritic rash with fluid-filled vesicles that began on the trunk. The physician says the child has varicella. The child's mother says to the nurse, 'I thought my child couldn't get this because she had all her shots.' What is the best response for the nurse to make?
A. You child probably did not respond to the vaccine as most children do.
B. The nurse must not have administered it correctly.
C. It is still possible to contract the illness, but your child will most likely have a less severe case.
D. The vaccine is only effective after the child has received two doses.
Explanation: The varicella vaccine reduces severity but does not guarantee immunity; breakthrough cases are milder, as indicated by the child's symptoms.
Question 4 of 5.
The nurse is caring for a client who is in ketoacidosis. Which blood gas values are most consistent with the diagnosis?
A. pH=7.32, pCO2=60, HCO3=30, pO2=60
B. pH=7.32, pCO2=32, HCO3=14, pO2=92
C. pH=7.50, pCO2=28, HCO3=24, pO2=90
D. pH=7.52, pCO2=50, HCO3=34, pO2=88
Explanation: Diabetic ketoacidosis causes metabolic acidosis: low pH, low HCO3, and low pCO2 due to compensatory hyperventilation.
Question 5 of 5.
The spouse of a client who had an angioplasty following a heart attack says to the nurse, 'What is an angioplasty? It sounds like plastic surgery. My husband had a heart attack.' What information should be included in the nurse's response?
A. An angioplasty repairs the heart damage caused by the heart attack.
B. During an angioplasty, the physician creates a bypass around blocked arteries, increasing the blood flow to the heart muscle.
C. Angioplasty is a diagnostic procedure to see if there are any blocked coronary arteries.
D. During an angioplasty, the physician uses a balloon-tipped catheter to open up an artery that is blocked by a clot, thus increasing blood flow to the heart muscle.
Explanation: An angioplasty is the insertion of a balloon-tipped catheter into a coronary artery. The balloon is inflated, opening up the artery and increasing blood flow through the coronary artery to the heart muscle. Angioplasty does not repair heart damage. A left heart cardiac catheterization is the diagnostic procedure that precedes angioplasty. Answer 2 describes a coronary artery bypass graft (CABG) procedure.
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