Question 1

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.

Accepted Answer

Performing a finger stick blood sugar is the most appropriate action because the symptoms described (tremors, high-pitched cry, diaphoresis) can be indicative of hypoglycemia, which is a common and urgent condition in newborns that needs to be addressed promptly.

Question 2

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.

Accepted Answer

Assessing for movement and sensation of the feet and legs is the highest priority action for a client with epidural analgesia as it indicates if the catheter has migrated or if there is any sign of neurotoxicity. This assessment should be done at least every shift to ensure client safety. Changing IV tubing with each bag of medication, keeping the head of the bed elevated, and monitoring peripheral pulses are important interventions, but they are not as high a priority as assessing for neurotoxicity.

Question 3

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.

Accepted Answer

As people age, they often experience decreased night vision due to changes in the eye, making it advisable to avoid driving at night.

Question 4

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

Accepted Answer

Keeping the stump elevated for the first 24 hours will help reduce swelling and promote circulation, which is important for healing and preventing complications such as infection or blood clots. Removing and reapplying the pressure dressing every 2 hours is not necessary and can potentially damage the surgical site. Complete bed rest for the first 48 hours is not recommended, as it can increase the risk of complications such as pneumonia, blood clots, and pressure ulcers. Treating phantom limb pain with a warm compress may provide temporary relief, but it is not the priority intervention at this time.

Question 5

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.

Accepted Answer

Giving the patient as much control over her care as possible is important in providing holistic care to a terminally ill patient. This includes involving her in decisions about her treatment, allowing her to express her preferences, and supporting her in maintaining her dignity and quality of life. Options A, C, and D may not be appropriate interventions in this situation. Option A may cause undue stress or unrealistic expectations for experimental treatments. Option C may focus on negative aspects of the patient's life, which may not be helpful in providing support. Option D may limit the patient's access to her loved ones, which can negatively impact her emotional well-being.

Question 6

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.

Accepted Answer

This intervention emphasizes the importance of validating the client's perception of reality without engaging in argument about the accuracy of these perceptions. It is important to acknowledge the client's feelings and thoughts without reinforcing delusions or challenging them directly. By using reality reinforcement, the nurse can redirect the conversation to a more constructive and grounded discussion.

Question 7

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

Accepted Answer

Keeping the doors and windows tightly closed in her room helps prevent air currents, which can cause discomfort over burn areas.

Question 8

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.

Accepted Answer

Encouraging the client to void just before the procedure is most appropriate because a full bladder is not required for an amniocentesis at 18 weeks gestation and can actually increase the risk of bladder injury during the procedure.

Question 9

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.

Accepted Answer

The patient's lack of bowel movement for 3 days could be causing constipation, which can interfere with the proper drainage of the peritoneal dialysis fluid. Evaluating and addressing constipation is a logical and non-invasive first step to improve fluid removal.

Question 10

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.

Accepted Answer

Trousseau's sign is an indicator of hypocalcemia. Therefore, the client should increase their intake of vitamin D and calcium to address the deficiency.

Question 11

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.

Accepted Answer

Compartment syndrome occurs when pressure within a muscle compartment increases and restricts blood supply to the tissues within. Removing the external sources of pressure (in this case, the splint, clothing, and socks) can decrease the pressure within the compartment and promote blood flow. Assessing pulses and skin color can help identify changes in blood supply, but removing the constricting pressure is the most effective measure to limit further complications. Elevating the ankle above the level of the heart and applying ace bandages may be helpful in reducing swelling, but they do not address the underlying issue of high compartment pressure.

Question 12

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.

Accepted Answer

The most therapeutic response is one that acknowledges the mother's feelings of uncertainty and offers support and assistance with the breastfeeding process. Option B does this by suggesting trying breastfeeding first and offering the nurse's presence and assistance. Option A uses language that may make the mother feel guilty or inadequate, while Option C assumes that the mother wants to bottle-feed and Option D uses language that is coercive and may increase the mother's anxiety.

Question 13

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.

Accepted Answer

It is important for the nurse to assess the fingers of the right hand for movement and sensation every 2 hours to ensure that there is no neurovascular compromise. This is crucial in preventing further complications such as compartment syndrome. The other options may also be important in caring for a client with a Fiberglas cast, but they are not the most important action in this situation.

Question 14

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.

Accepted Answer

The highest priority nursing action in the edematous phase of nephrotic syndrome for a 2-year-old boy is to clean and powder the skin folds every 2 hours to prevent skin breakdown and potential infection due to excess fluid and edema in the body. While monitoring intake and output is important, it is not the highest priority in this phase of nephrotic syndrome. Increasing fluid intake may exacerbate edema and encourage fluid retention, and encouraging active play may not be appropriate or feasible for a child experiencing edema.

Question 15

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.

Accepted Answer

The teaching point that the nurse should include in the discharge plan for a renal transplant client about the risks of infection postoperatively is that if the client develops fever, chills, joint pain, or headache, they should contact the physician immediately. This is because infections can occur easily in transplant clients, and prompt identification and treatment of infection is crucial to prevent further complications. The other options are not accurate and may lead to misunderstanding or inappropriate behavior on the part of the client.

Question 16

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.

Accepted Answer

Option A is not an appropriate intervention as taking away a child's favorite toy is likely to cause distress and could further exacerbate the child's unwillingness to stay in the tent. Option B is also not an appropriate intervention and could be considered inappropriate and insensitive. Option C should be a last resort as medicating a child with a sedative for this situation is not ideal and should only be considered if all other interventions have failed. Option D is the most developmentally appropriate intervention as engaging the child in a fun activity (such as playing a board game with his mother) while in the mist tent can distract the child and make the experience less frightening. This intervention would likely increase the child's compliance with the treatment.

Question 17

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

Accepted Answer

Increasing the sensitivity setting allows the ventilator to more easily detect the patient's attempts to initiate a breath, which is essential when switching to assist/control mode to ensure the machine assists with ventilation efforts initiated by the patient.

Question 18

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."

Accepted Answer

Kayexalate is a medication that works by exchanging sodium ions for potassium ions in the intestines, which helps to decrease the level of potassium in the blood. This is important for patients with chronic renal failure as their kidneys may not be functioning properly to remove excess potassium.

Question 19

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.

Accepted Answer

Avoiding actions that increase intracranial pressure, such as blowing the nose, coughing, or sneezing, is crucial after a transsphenoidal hypophysectomy to prevent complications like cerebrospinal fluid leak.

Question 20

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

Accepted Answer

Administering prescribed systemic antibiotics is the highest priority intervention for a client with severe impetigo as it will target the underlying bacterial infection causing the impetigo. Topical antibiotic ointment and covering hands with gauze or mitts are important interventions, but they address superficial symptoms and do not address the underlying infection. Tepid baths may provide comfort to the client but are not the priority intervention.

Quiz 11: Nclex: What You Need to Know

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.

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.

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.

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.

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 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 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.

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.

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

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.

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

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.

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.

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

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.

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 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?"

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

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