NCLEX Trainer Test 6
Question 1 of 5.
Extract:A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
A. Utilize an organized team to place the client in seclusion.
B. Leave the client alone in his room to identify feelings of anger.
C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Explanation: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion
Question 2 of 5.
A registered nurse (RN) asks the licensed practical nurse (LPN) to hang blood on a client. What is the best response by the LPN?
A. Carefully check the order and the client identification and hang the unit if all is in order.
B. Ask the RN to verify the order and then administer as ordered.
C. Hang the blood after taking baseline vital signs.
D. Refuse to administer the blood.
Explanation: LPN scope of practice typically excludes initiating blood transfusions due to the need for specialized monitoring, requiring RN administration.
Question 3 of 5.
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
A. The client states that he will not spend much time in the sun.
B. The client says to the nurse, 'Is this the correct way to check my pulse? I want to do it right.'
C. The client tells the nurse he will be very careful to sit on the edge of the bed for a few moments before standing up.
D. The client says, 'I will not take Cialis while I am taking this medicine.'
Explanation: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
Question 4 of 5.
An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
A. How do you manage your bowels?
B. When was your last menstrual period?
C. What are your favorite foods?
D. When was your last tetanus shot?
Explanation: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
Question 5 of 5.
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
A. Check pedal pulses.
B. Check legs for pitting edema.
C. Upper extremity neuro checks.
D. Auscultate lung sounds.
E. Observe respirations.
F. Observe for gait disturbances.
Explanation: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Related Questions