NCLEX Trainer Test 5
Question 1 of 5.
The nurse is caring for a client with a history of falls.
A. Which intervention should be included in the care plan for a client with a history of falls?
B. Keep the bed in a high position to discourage getting out of bed.
C. Encourage the client to remain in bed as much as possible.
D. Place a night light in the bathroom.
E. Restrict the client's fluid intake in the evening.
Explanation: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.
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.