NCLEX RN Practice Questions Quizlet
Question 1 of 5.
The nurse is caring for a client on a ventilator that is set on intermittent mandatory ventilation (IMV). Assessment on the ventilator is IMV mode of 8 breaths per minute. The nurse assesses the client's respiratory rate of 13 per minute. These findings indicate that:
A. The client is 'fighting' the ventilator.
B. Pressure support ventilation is being used.
C. Additional breaths are being delivered by the ventilator.
D. The client is breathing five additional breaths on his own.
Explanation: IMV delivers a set number of breaths (8 per minute), but the client can breathe spontaneously. A respiratory rate of 13 indicates the client is taking 5 additional spontaneous breaths (13 - 8 = 5).
Question 2 of 5.
A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following?
A. The nurse’s opinion regarding the mental and emotional status of the client.
B. Data addressing the client’s emotional state.
C. Data that address a biopsychosocial approach, including a family system assessment.
D. Specific data detailing the client’s mental status.
Explanation: complete nursing history includes biopsychosocial data; client’s psychosocial and physical status are evaluated along with an assessment of the client’s family system and social support network; evaluation of the client’s cognitive ability is important during the physiological status assessment
Question 3 of 5.
The nurse is caring for an 80-year-old client with Parkinson’s disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client?
A. Return the client to usual activities of daily living.
B. Maintain optimal function within the client’s limitations.
C. Prepare the client for a peaceful and dignified death.
D. Arrest progression of the disease process in the client.
Explanation: irreversible disease that leads to permanent physical limitations
Question 4 of 5.
A 2-month-old boy with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that her son had a DPT injection one week ago, and asks if this fever is related to the immunization. The nurse’s response should be based on the knowledge that
A. if a fever does occur in a child after a DPT, it usually occurs within the first 2 hours.
B. an elevated temperature is very rarely seen in a child after a DPT immunization.
C. if there is a fever after a DPT, it usually low-grade and appears within the first 48 hours.
D. the child’s high fever is a direct response to the DPT immunization and should be treated.
Explanation: low-grade fever and irritability frequent response to immunization
Question 5 of 5.
The nurse is preparing to administer digoxin (Lanoxin) 0.25 mg IV to a client with heart failure. Prior to administration, the nurse checks the client’s apical pulse and finds it to be 52 beats per minute. Which of the following actions should the nurse take?
A. Administer the medication as ordered.
B. Withhold the medication and notify the physician.
C. Administer half the dose and monitor the client.
D. Recheck the pulse in 30 minutes and then administer the medication.
Explanation: digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as it can exacerbate bradycardia
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