Deck 11: Nclex: What You Need to Know

Question 1

What is the maximum number of questions that a graduate may answer on the NCLEX-RN CAT?

A)60
B)75
C)265
D)355

Answer 1

265

Question 2

Select the discharge instruction to a client diagnosed with multiple sclerosis (MS) that most reduces the risk potential for complications.

A)Take cool baths or showers only.
B)Midday naps will interfere with your ability to sleep at night.
C)Avoid high-fiber foods such as fresh fruits and vegetables.
D)Limit your fluid intake to 1000 mL a day to prevent incontinence.

Answer 2

Take cool baths or showers only.

Question 3

Which test-taking tip is most important to remember when taking a multiple choice examination such as the NCLEX-CAT, RN?

A)Read each question four times so that related information can be remembered.
B)To save time, select the first answer that is correct.
C)Ignore negative words in the stem question because they confuse the issue.
D)Avoid reading into the question information that is not included in the client situation.

Answer 3

Avoid reading into the question information that is not included in the client situation.

Question 4

What is an important factor to remember for graduates who decide to use group study as a means of preparing for the NCLEX-CAT, RN examination?

A)A group of at least 15 students is needed for optimal study.
B)Make sure that study sessions are at least 3 hours long for the most efficient use of time.
C)Have each group member prepare a section of the topic for study during that session.
D)Bring large quantities of chips, candy, pizza, and soda to the session to maintain energy levels.

Question 5

While taking the NCLEX-RN, CAT examination, a graduate encounters a question about a disease process that had not been covered in any class in nursing school. Which strategy would be best for the graduate to use in answering this question?

A)Look for a totally unfamiliar answer and select it because it probably relates to the unknown disease process.
B)Select answer A and move on to the next question.
C)Try to remember a question earlier in the examination that dealt with a similar situation and apply that information to the current question.
D)Select the answer that appears logical and involves general nursing care.

Question 6

How is the nursing process treated by the NCLEX-CAT, RN?

A)It is a five-step process that involves assessment, analysis, planning, implementation, and evaluation.
B)It is a four-step process that involves assessment, planning, implementation, and evaluation.
C)It is unimportant, and no questions are asked about it.
D)It is the most important part of the examination.

Question 7

Identify the stem question that best indicates that an "Evaluation" category question is being asked.

A)Which of these actions should the nurse perform first?
B)You know your teaching concerning colostomy care was successful if the client makes which statement?
C)Identify the data that are most important to obtain for a client with cardiac disease.
D)Which nursing diagnosis has the highest priority?

Question 8

In which health needs categories of the NCLEX-CAT, RN examination would the student find questions about a pregnant woman?

A)Safe and effective care environment
B)Psychosocial needs
C)Health promotion and maintenance needs
D)Physiological needs

Question 9

The mother of four children brings her 6-year-old girl to the public health well-child clinic because the child has "scratched herself raw." The public health nurse diagnoses the child as having scabies and gives the mother appropriate medication for the child's treatment. Select the most appropriate instructions by the nurse to the mother of these four children.

A)Avoid sharing towels and linens with the infected child.
B)Treat the other children immediately.
C)Treat the other children only if symptoms develop because the medication has many side effects.
D)Wash the family's hair in strong detergent shampoo.

Question 10

Which stem question best indicates that an "Implementation" category question is being asked?

A)Which action should the nurse perform first?
B)You know your teaching concerning colostomy care was successful if the client makes which statement?
C)Identify the data that are most important to obtain for a client with cardiac disease.
D)Which nursing diagnosis has the highest priority?

Question 11

A stem questions states: "A client admitted with BUN of 64 and a creatinine of 6 would require which nursing actions first?" What cognitive level does this stem question indicate?

A)Level 1, recall question
B)Level 2, analysis question
C)Level 3, synthesis question
D)Level 4, advanced question

Question 12

Which word found in a stem question would make the question negative?

A)First
B)Atypical
C)Highest priority
D)Appropriate

Question 13

A 28-year-old woman is diagnosed with systemic lupus erythematosus (SLE). Select the discharge instructions by the nurse that best help prevent exacerbation of the disease.

A)Avoid using birth control pills and stay out of the bright sun.
B)Make sure to take your penicillin and sulfa antibiotics as prescribed.
C)Avoid foods that are high in potassium and protein.
D)Once you go into remission, you can stop taking your prednisone.

Question 14

Select the stem question that best indicates that an "Assessment" category question is being asked.

A)Which action should the nurse perform first?
B)You know your teaching concerning colostomy care was successful if the client makes which statement?
C)Identify the data that are most important to obtain for a client with cardiac disease.
D)Which nursing diagnosis has the highest priority?

Question 15

Which stem question best indicates that an "Analysis" category question is being asked?

A)Which action should the nurse perform first?
B)You know your teaching concerning colostomy care was successful if the client makes which statement?
C)Identify the data that are most important to obtain for a client with cardiac disease.
D)Which nursing diagnosis has the highest priority?

Question 16

Identify the action that the nurse should take first when a 12-year-old boy who is sitting in a chair begins to have a tonic-clonic seizure.

A)Restrain the child to prevent injury to his arms and legs.
B)Pad the environment around the chair.
C)Quickly insert an oral airway in his mouth to keep the airway patent.
D)Move him to a flat surface and position him on his side.

Question 17

In the abbreviation NCLEX-CAT, RN, what does CAT stands for?

A)Computerized assistive testing
B)Complex assessment technique
C)Computerized assessment testing
D)Computerized adaptive testing

Question 18

What statement is most accurate about the NCLEX-CAT, RN?

A)It is a certification examination taken by all nurses.
B)It is too difficult for most new graduates to pass the first time.
C)It is unnecessary in states where institutional licensure is the rule.
D)It is required of all nurses for licensure.

Question 19

Identify the correct procedure that a graduate who fails the NCLEX-CAT, RN must follow.

A)Wait 45 days before retaking the examination.
B)Retake only the portion of the examination that was failed.
C)Repeat an approved "refresher" course before taking the examination a second time.
D)Retake the examination immediately.

Question 20

Which statement made by a student after a class on the NCLEX-CAT, RN test indicates that the student has a good understanding of the examination?

A)Partial credit is given for close answers.
B)The sequence of questions is determined by the difficulty level.
C)High levels of computer skills are needed to complete the test successfully.
D)The graduate is allowed to go back and change the answers of questions answered previously on the examination.

Question 21

A client receives an autograft of skin from his abdomen to his right arm after suffering a third-degree burn from a campfire. Select the instructions by the nurse that best insure that the newly grafted skin is not rejected.

A)Decrease your protein intake to 60 grams per day.
B)Increase your fluid intake to 2 to 3 liters per day.
C)Avoid going outside for 2 weeks after you are discharged from the hospital.
D)Keep your right arm in a sling with minimal range of motion for 2 weeks.

Question 22

Identify the action by the public health nurse that best reduces the risk for infection of a man who now has a positive purified protein derivative (PPD) skin test and whose wife was recently diagnosed with active pulmonary tuberculosis.

A)Obtain a list of names of other persons his wife has come into contact with.
B)Instruct the man that he has to remain in isolation for 1 week.
C)Begin a 6- to 12-month course of treatment with rifampin (Rafadin).
D)Readminister the PPD because it may be a false positive.

Question 23

Identify the action by the nurse that would promote the optimal effectiveness of Bryant's traction for a 3-year-old child in the pediatric unit who sustained a fractured femur in a fall from his front porch.

A)Maintain the hips at a 90-degree angle to the body.
B)Allow the parents to remain with the child as much as possible.
C)Place a sheepskin pad under the child to prevent skin breakdown.
D)Make sure the traction weights are resting against the side of the crib to reduce the excessive pull on the bones.

Question 24

Identify the activity instructions given by the nurse at the time of discharge to a client with acute hepatitis A that best promote the client's recovery.

A)Except for going to the bathroom, you should stay in bed.
B)Start walking short distances as soon as you feel strong enough.
C)Active, isometric-type exercises performed four times a day will help prevent muscle atrophy.
D)You may work at your computer for no more than 4 hours per day.

Question 25

Identify the instructions by the nurse that best help prevent complications from renal disease in a client who is being prepared for hemodialysis due to end-stage renal disease secondary to polycystic kidney disease.

A)Make sure you drink 2 to 3 liters each day to prevent cramps.
B)Increase your intake of fresh fruits such as bananas and oranges.
C)Limit your sodium intake and avoid using a salt substitute.
D)Eat 3 to 5 ounces of meat at each meal to prevent catabolism.

Question 26

Choose the position that the nurse should place a client in to best relieve the midsternal chest pain caused by pericarditis secondary to a viral infection.

A)Head elevated 30 to 40 degrees
B)Flat in bed in the supine position
C)Trendelenburg's to help promote drainage of the excessive pericardial fluid
D)Sitting up 90 degrees and leaning forward

Question 27

Select the action by the nurse that best helps promote the adaptation of a client in Addisonian crisis.

A)Assign the client to a private room.
B)Cover the client with one or two extra blankets to keep him warm.
C)Ambulate the client four times per day to maintain exercise tolerance.
D)Encourage the client to take a shower instead of a bed bath.

Question 28

Select the most effective action a nurse can take to protect a client who has been recently diagnosed with thrombocytopenia.

A)Have the client use a wheelchair whenever the client must leave the room.
B)Increase the client's fluid intake to 3 liters per day to prevent a urinary tract infection.
C)When giving intramuscular injections, use the smallest needle possible to administer the medication.
D)Limit visits to immediate family only for 10 minutes per hour.

Question 29

Identify the nursing intervention that has the highest priority for a client who is experiencing hemiparesis secondary to an intercerebral blood clot (stroke).

A)Position the client on the affected side.
B)Encourage the client to perform active range of motion exercises every 4 hours.
C)Place hand rolls in the hands to prevent contractures.
D)Keep the head of the bed flat to prevent dizziness.

Question 30

A client is admitted to the medical/surgical unit with acute pancreatitis secondary to a viral infection. Select the action by the nurse that is most important in promoting healing of the pancreas.

A)Place the client in the prone position to increase comfort.
B)Maintain the client in a strict nothing-by-mouth (NPO) status.
C)Decrease the IV intake to prevent cardiac overload.
D)Administer prescribed IV antibiotics on schedule.

Question 31

Identify the nursing action that is most appropriate when the nurse assesses a small amount of clear, watery fluid oozing from the nose of a client who received a blow to the head in a barroom fight.

A)Encourage the client to blow his nose to clear the sinuses.
B)Use a dipstick to test the drainage for glucose.
C)Keep the client's head flat.
D)Ask the client about what type of object he was struck with.

Question 32

After a third episode of cystitis, a client asks the nurse what she can do to prevent another infection. The nurse recommends that the client follow an acid-ash diet and avoid which of the following foods?

A)Cranberry and orange juice
B)Milk and apples
C)Coffee and tea
D)Prune juice and plums

Question 33

The pulse oximeter connected to a client with viral pneumonia, but who has no other underlying respiratory disease, has had readings between 79% and 88% for the past half hour. Identify the type of oxygen delivery system that is most effective for the nurse to initiate when the client complains of shortness of breath.

A)Nonrebreather mask
B)Nasal cannula
C)Rebreather mask
D)High-humidity face tent

Question 34

After a stab wound to the chest, a client develops a pneumothorax and has a chest tube inserted in the emergency room (ER) that is connected to a self-contained underwater-seal drainage system (pleur-evac). Select the action the ER nurse should take first when she notices that the second chamber has stopped bubbling.

A)Remove any blockages from the drainage tube.
B)Tape all connections to eliminate leaks in the system.
C)Change out the drainage system because the first one is obviously defective.
D)Increase the suction to 120 mm Hg negative pressure.

Question 35

Identify the statement made by the nurse during the discharge instructions to a client with a hiatal hernia that best aids in the prevention of gastrointestinal discomfort.

A)You may eat three large meals a day but limit carbohydrate intake.
B)If you lie down right after you eat, the food will digest more thoroughly.
C)Try to eat six bland small meals per day that are high in fiber.
D)Drinking two to three glasses of water with each meal will prevent reflux.

Question 36

A 32-year-old woman who has a fractured T-7 following an automobile accident develops urinary retention. The physician orders intermittent catheterizations every 6 hours, and the nurse obtains between 600 and 830 mL of urine each time. Select the most appropriate nursing action for this client.

A)Notify the physician and obtain an order for a Foley catheter.
B)Restrict the client's fluid intake to 500 mL per shift.
C)Obtain an order to catheterize the client every 3 to 4 hours.
D)Continue catheterizing the client per the physician's order.

Question 37

Select the action that the nurse should take after finding a firm nodule during a scrotal examination of a 32-year-old man.

A)Notify the client's urologist.
B)Perform a rectal examination for abnormalities of the prostate gland.
C)Prepare the client for a follow-up ultrasound to confirm the diagnosis.
D)Use a flashlight to transilluminate the scrotum.

Question 38

Select the position that is best for the nurse to keep a client in who received a head injury in a sports accident and has his neck stabilized in a neck collar.

A)Flat in the supine position
B)Trendelenburg's position
C)Low Fowler's position with the head elevated 30 degrees
D)Side-lying position with the legs flexed slightly

Question 39

Identify the initial action that the nurse should take to treat an acute episode of diabetic ketoacidosis (DKA) in a client with type I, insulin-dependent diabetes mellitus.

A)Administer 50 units of regular insulin intravenously.
B)Start an intravenous (IV) line of 0.45% normal saline at 150 mL per hour.
C)Administer 2 amps of sodium bicarbonate.
D)Ask the client if he has taken his insulin that morning.

Question 40

Identify the action by the nurse caring for a client who has just returned from extracorporeal shock wave lithotripsy that best promotes the client's physiological adaptation.

A)Increase fluid intake to 2 to 3 liters per day.
B)Evaluate his vital signs every 2 hours.
C)Use an antimicrobial ointment and sterile dressing on the incision site.
D)Report any blood in the urine to the physician immediately.

Question 41

Select the communication technique that is most appropriate for the nurse to use when working with a client who has both eyes patched.

A)Speak loudly and clearly so the client can understand better.
B)Identify himself or herself each time the nurse enters the client's room.
C)Enter and leave the room quietly so as not to startle the client.
D)Touch the client only when absolutely necessary.

Question 42

Identify how the nurse can best assess the blood pressure of a client who develops lymphedema in both arms after a bilateral mastectomy.

A)Take the blood pressure in the arm but alternate arms each time it is taken.
B)Take the blood pressure in the thigh using a thigh cuff.
C)Assess the client's capillary refill and extremities for color, warmth, and sensation.
D)Use an arm cuff for consistency but take the blood pressure in the thigh area.

Question 43

Identify the intervention by the nurse that is most appropriate in caring for a client with a recent diagnosis of acute pancreatitis.

A)Administer a prescribed as-needed (PRN) pain medication.
B)Reduce the IV rate to 50 mL per hour to prevent fluid overload.
C)Encourage the client to increase his intake of protein to promote healing.
D)Position the client with his head elevated 45 degrees.

Question 44

Select the action by the nurse that is most appropriate for a 32-year-old woman diagnosed with Sjögren's syndrome.

A)Select a diet for the client with foods high in potassium, such as oranges and bananas.
B)Use a moisturizing emollient on the client's skin after a shower.
C)Instruct the client to take a multivitamin plus iron each day when discharged.
D)Maintain the client's bed so that the head is elevated 30 to 45 degrees.

Question 45

Select the nursing action that takes highest priority in the care of a client with a chest tube connected to a closed underwater-seal drainage system.

A)Strip or milk the chest and drainage tube every 2 hours.
B)Make sure there is continuous bubbling in the underwater-seal chamber.
C)Record the amount of drainage in the drainage collection chambers every 8 hours.
D)Hang the drainage collection system at chest level to promote optimal function.

Question 46

During her first month postpartum, a woman who is breast feeding her baby develops unilateral mastitis. Select the statement by the nurse that demonstrates an appropriate use of the therapeutic communication technique called self-disclosure.

A)I remember the discomfort I had after my first child and how quickly it went away after I started taking antibiotics.
B)You seem to be very anxious about the condition.Tell me how you think it will affect your ability to breast feed.
C)This is a common and relatively minor problem, and you should be better in 2 to 4 days.
D)The infection is not your fault.The organism probably came from the respiratory tract of your baby.

Question 47

Identify the initial action by the ER nurse that is most appropriate for a 42-year-old woman diagnosed with a mood disturbance disorder who overdoses on amitriptyline (Elavil).

A)Induce vomiting by administering 30 mL of syrup of Ipecac.
B)Initiate an IV of normal saline at 200 mL per hour.
C)Lavage the stomach with a #14 nasogastric tube to prevent trauma.
D)Administer activated charcoal 50 g every 4 hours for 24 hours.

Question 48

Select the action that the clinic nurse should take first when an adult client with a severe sunburn of the chest, back, face, and legs is seen in the clinic.

A)Begin an IV line of D5/0.45NS to run at 150 mL per hour.
B)Give the client a prescribed pain medication.
C)Apply a prescribed antimicrobial ointment to the burn areas to prevent infection.
D)Discuss with the client the risks of developing skin cancer related to repeated sun exposure.

Question 49

Choose the dietary recommendations that are most appropriate for the nurse to make to a client who was diagnosed with hypoparathyroidism.

A)Increase your intake of vitamin D and calcium.
B)Increase your intake of potassium and iron.
C)Decrease your intake of calcium and phosphate.
D)Increase your intake of folic acid and decrease your intake of sodium.

Question 50

Identify the initial action by the nurse that is most appropriate for a 10-year-old boy who is seen in the ER with a partially detached retina on the left side of the left eye after sustaining a head injury during a baseball game.

A)Cover both eyes with a soft eye patch.
B)Position the client on the right side with his head slightly elevated.
C)Irrigate the left eye with a gentile stream of normal saline.
D)Position the client on the left side with his head flat.

Question 51

Select the teaching point the nurse should include in the discharge instructions for a client with asthma about the mode of action of the home medication cromolyn sodium (Intal).

A)Produces bronchodilation
B)Reduces the production of mucus
C)Liquefies and thins thick mucus secretions so they can be coughed out
D)Blocks the release of bronchoconstrictors from the mast cells

Question 52

Select the action by the nurse that best helps reduce intracranial pressure in a client who sustained a head injury after a diving accident.

A)Use a manual respirator (ambu-bag) to hyperventilate the client.
B)Have the client breathe slowly into a paper bag.
C)Administer 1 amp of sodium bicarbonate intravenously slowly.
D)Maintain the client in a supine position.

Question 53

Select the position that is most appropriate for a client who just returned from a myelogram in which a water-soluble contrast medium (metrizamide) was used.

A)Trendelenburg's
B)Prone
C)Supine/flat
D)Head elevated 45 degrees

Question 54

Identify the nursing action that best prevents the introduction of air into a subclavian IV line when the nurse is changing the tubing on the IV solution.

A)Keep the head of the bed elevated 45 degrees.
B)Have the client turn his head away from the insertion site.
C)Encourage the client to do the Valsalva's maneuver during the procedure.
D)Make sure the tubing on the old IV line is turned off before changing.

Question 55

Four clients are brought to the ER for treatment after a severe motor vehicle accident. Identify the client that the triage nurse would send for treatment first.

A)A 23-year-old third-trimester pregnant woman who is having contractions
B)A 42-year-old man who has a crushed cranium and no blood pressure or pulse
C)A 61-year-old woman having gurgling respirations secondary to a maxillofacial injury
D)An 8-year-old boy with lower-extremity paralysis secondary to a lumbar spinal cord injury

Question 56

A client with pancreatitis complains of abdominal pain. If the physician has prescribed all of the following medications PRN for pain for this client, identify the one the nurse should give.

A)Morphine sulfate, 5 to 10 mg IV
B)Propoxyphene HCL (Darvon), 65 mg PO
C)Meperidine (Demerol), 25 to 50 mg IV
D)Acetaminophen (Tylenol), 650 mg PO

Question 57

Choose the nursing action that is most appropriate for the collection of a stool specimen from a 3-year-old child who has had diarrhea for the past 4 days.

A)Use a preservative solution after the specimen is obtained.
B)Store the specimen in the refrigerator until it can be taken to the lab.
C)Place the specimen in a sterile container.
D)Collect an entire stool.

Question 58

A post-C-section client who had the procedure under an inhalation anesthetic begins to experience severe shivering in the recovery room. In addition to covering the client with extra blankets, select another appropriate action to be taken by the nurse.

A)Raise the temperature of the room by increasing the thermostat.
B)Call the surgeon and notify of the deterioration in the client's condition.
C)Apply the prescribed oxygen by face tent.
D)Decrease the IV rate to reduce the amount of cold fluid entering the client's cardiovascular system.

Question 59

Identify the discharge instructions by the nurse for a client diagnosed with Addison's disease that most accurately describes how the client should take fludrocortisone acetate and hydrocortisone at home.

A)Take two thirds of the dose when you wake in the morning and the remaining one third late in the afternoon.
B)Take the hydrocortisone in the morning with breakfast and the fludrocortisone in the afternoon on an empty stomach.
C)Take both medications before you go to bed at night.
D)Take both medications when you wake up in the morning.

Question 60

Select the action the nurse should take first when a client becomes short of breath, pale, and diaphoretic and complains of localized chest pain after a new bottle of TPN has been hung.

A)Bring the code cart into the room and prepare for cardiac pulmonary resuscitation.
B)Place the bed in Trendelenburg's position and turn the client on the left side.
C)Keep the head and body flat and elevate the legs.
D)Notify the physician that the client is having a myocardial infarction.

Question 61

Identify the nursing action that is most appropriate for the nurse to take when caring for a newborn who has tremors, has a high-pitched cry, and is diaphoretic.

A)Obtain urine for drug screen for cocaine.
B)Perform a finger stick blood sugar.
C)Cover the infant's head with a cap.
D)Give the infant 1 ounce of sterile water.

Question 62

Select the action by the nurse that has the highest priority in the care of several clients who are receiving postoperative pain management by epidural analgesia on the surgical unit.

A)Change the IV tubing with each bag of medication.
B)Keep the head of the bed elevated 30 degrees to prevent hypotension.
C)Monitor peripheral pulses every 2 hours.
D)Assess for movement and sensation of the feet and legs each shift.

Question 63

Select the instructions given by the nurse to a group of senior citizens attending a class on aging at a senior center that best addresses the normal age-related changes in vision.

A)You may have problems seeing blue or black objects against a yellow wall.
B)Your central vision is poorer, so you may not see objects in front of you.
C)Try to avoid driving at night due to decreased night vision.
D)It is not unusual to see rainbows or halos around artificial lights.

Question 64

Identify the intervention by the nurse that is most appropriate when providing care for a client who has just returned to the surgical unit with a below-the-knee amputation.

A)Keeping the stump elevated for the first 24 hours
B)Removing and reapplying the pressure dressing every 2 hours to prevent necrosis
C)Keeping the client on complete bed rest for the first 48 hours
D)Treating the phantom limb pain by applying a warm compress to the stump

Question 65

Choose the nursing intervention that is most appropriate in providing care to a 28-year-old mother of two children who is in the terminal stages of ovarian cancer but is still able to communicate.

A)Instruct her in the benefits and risks of new experimental cancer treatments.
B)Give her as much opportunity as possible for control over her care.
C)Allow her to verbalize her regrets and shortcomings of her life.
D)Limit the number of visits by her children to two per day.

Question 66

A 44-year-old woman who is diagnosed with paranoid personality disorder is seen in the clinic for treatment. Select the intervention by the nurse that best achieves the goal of promoting consensual validation of reality.

A)Challenge her delusional perceptions by joking in a nonthreatening way about how unrealistic they are.
B)Use reality reinforcement and avoid arguing with the client about her perceptions.
C)Use distraction when the client begins to expound about her perceptions.
D)Administer a prescribed PRN antianxiety medication 1 hour before attempting to council with the client.

Question 67

A 23-year-old woman with partial and full thickness burns over 28% of her body is being treated with the "open method" of burn treatment. Select the nursing action that best helps prevent discomfort caused by air currents over the burn areas.

A)Keeping her well sedated
B)Adding humidity to the room air
C)Supporting her upper limbs on a bed cradle
D)Keeping the doors and windows tightly closed in her room

Question 68

Select the action by the nurse in the obstetrical clinic that is most appropriate in preparing a client at 18 weeks gestation for an amniocentesis.

A)Encourage her to void just before the procedure.
B)Post all blood work on the chart.
C)Give her a prescribed sedative medication 1 hour before the procedure.
D)Have her drink two glasses of water to make sure her bladder is full.

Question 69

For the past three exchanges, a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) has retained between 250 and 400 mL with each exchange. He has no urine output and has not moved his bowels in 3 days. The returned CAPD fluid is clear. Select the most appropriate action by the nurse at this time.

A)Increase the glucose concentration of the fluid to pull off more fluid.
B)Cap the catheter and notify the physician.
C)Evaluate the patient for possible constipation.
D)Skip the next exchange and allow the fluid to drain.

Question 70

Identify the dietary instructions by the nurse that are most appropriate for a client who has a positive Trousseau's sign.

A)Decrease your intake of calcium and phosphate.
B)Increase your intake of potassium and iron.
C)Increase your intake of vitamin D and calcium.
D)Increase your intake of folic acid and decrease your intake of sodium.

Question 71

Identify the best measure the nurse can take to limit the complications of a client who is developing compartment syndrome after a splint is applied to a fractured ankle.

A)Remove the splint, clothing, socks, and other external sources of pressure.
B)Assess the pulses and skin color every 2 hours.
C)Make sure the ankle is below the level of the heart.
D)Apply ace bandages to the foot to decrease the swelling.

Question 72

Choose the most therapeutic response by the nurse to a new mother who verbalizes uncertainty about her ability to breast feed her new baby.

A)Breast feeding a baby is best.Bottle feeding is only a poor substitute for women who can't produce enough milk.
B)Let's try the breast feeding first and see how you do.I'll be right here to help you with the process.
C)We can give him a bottle until your milk comes in and you feel more sure about your ability to breast feed.
D)If you don't make up your mind right away, we'll be forced to bottle feed him.

Question 73

Identify the action by the nurse that is most important in providing care for a client who has a Fiberglas cast on her right arm.

A)Cover the cast with a pillowcase to keep the arm warm.
B)Keep a cast cutter at the bedside.
C)Assess the fingers of the right hand for movement and sensation every 2 hours.
D)Elevate the cast 45 degrees for the first 48 hours.

Question 74

Identify the nursing action that takes the highest priority in the care of a 2-year-old boy in the edematous phase of nephrotic syndrome.

A)Increase fluid intake to 1000 mL per day.
B)Encourage the child to play actively for 10 minutes each hour.
C)Clean and powder the skin folds every 2 hours.
D)Monitor intake and output every 24 hours.

Question 75

Identify the teaching point the nurse should include in the discharge plan for a renal transplant client about the risks of infection postoperatively.

A)If you develop fever, chills, joint pain, or headache, contact the physician immediately.
B)You can stop taking your Prograft if you start to feel sick or if you are very tired.
C)You will never be able to go to church or go any place where there are crowds of people.
D)You should avoid going to the dentist or the gynecologist for at least a year after your surgery.

Question 76

A 30-month-old boy with acute bronchitis and respiratory distress is admitted to the pediatric unit for croup (mist tent treatment). Choose the intervention by the nurse that is developmentally most appropriate when the child refuses to stay in the tent.

A)Take away his favorite toy until he decides to remain in the tent.
B)Tell him a story about how a little boy died because he did not stay in the tent.
C)Medicate him with a sedative to reduce anxiety and calm him.
D)Instruct his mother to play a board game with him while sitting in the tent.

Question 77

Identify the additional changes in the ventilator settings the nurse needs to make when changing a ventilator client from full-control mode to assist/control mode.

A)Increase in the sensitivity setting
B)Decrease in the FIO₂
C)Increase in the FIO₂
D)Decrease in the sensitivity setting

Question 78

A client in chronic renal failure asks the nurse, "Why must I drink this awful-tasting Kayexalate 4 times a day?" Which of the following explanation by the nurse would be most appropriate?"

A)"If you do not drink it, we'll have to give it as an enema."
B)"It will help lower your potassium level by exchanging sodium ions for potassium ions in your intestines."
C)"It will help increase your urine output by stimulating your kidneys and promoting the movement of water into the tubule system."
D)"It will prevent infections by decreasing the bacteria in your intestinal tract."

Question 79

Select the instructions by the nurse to a postoperative client who had a transsphenoidal hypophysectomy that best promote his recovery.

A)If you have any ringing in your ears, let me know right away.
B)Please keep your head flat for the first 12 hours after surgery.
C)Do not blow your nose, cough, or sneeze for the first 48 hours after surgery.
D)You must increase your fluid intake to 2 liters of fluid per day.

Question 80

Select the intervention that the nurse places highest priority on when caring for an adult client with severe impetigo.

A)Using a circular motion to apply prescribed topical antibiotic ointmenta.m.and one in the p.m.
B)Covering the client's hands with gauze or mitts to prevent scratching
C)Administering prescribed systemic antibiotics
D)Giving the client two tepid baths, one in the