NCLEX Trainer Test 10
Question 1 of 5.
Extract:An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
The nurse should
A. decrease the IV rate to 20 cc/h and notify the physician.
B. decrease the IV rate to 100 cc/h and continue to monitor the client.
C. discontinue the IV and start oxygen at 6 L/min.
D. assess for infiltration of the IV solution.
Explanation: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
Question 2 of 5.
Extract:A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
C. Help the client obtain a sponsor through a 12-step group in the client's local area.
D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Explanation: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
Question 3 of 5.
Extract:A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
B. I'll use a tongue blade to collect a small amount of stool in a clean container.
C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
D. I'll ask the patient if he has ingested any red meat recently.
Explanation: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
Question 4 of 5.
Extract:A client comes to the nurse's station for her antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes.
Which of the following action should the nurse take FIRST?
A. Determine what other medications the patient is taking.
B. Perform a neurological assessment.
C. Administer haloperidol decanoate (Haldol D) IM stat.
D. Administer the PRN trihexyphenidyl (Artane) IM immediately.
Explanation: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment, demonstrating acute extrapyramidal side effects (2) assessment, no validation required (3) Haldol is antipsychotic, will exacerbate symptoms (4) correct-administer Cogentin or Artane
Question 5 of 5.
Extract:The nurse is caring for patients on the surgical floor and has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
A. A 35-year-old admitted three hours ago with a gunshot wound; 1/5 cm area of dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy two days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no drainage noted from chest tube in last eight hours.
D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills.
Explanation: Strategy: Think ABCs. (1) does not indicate acute bleeding, small amount of blood (2) expected outcome (3) indicates resolution (4) correct-risk for peritonitis, should be assessed for further symptoms of infection
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