NCLEX Trainer Test 7
Question 1 of 5.
Extract:A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
A. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn.
B. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision.
C. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
D. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Explanation: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly
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.
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