nclex 3

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nclex 3
2012-04-13 03:34:50

nclex 3
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  1. 59. Which of the following statements by a client indicates understanding of strict neutropenic precautions?1. “I can eat lots of fresh bananas.”2. “I can have imitation plants in my room.”3. “I can eat lots of fresh tomatoes.”4. “I can eat lots of fresh cucumbers.”
    (2) The client may not have any fresh fruits, fresh vegetables, or live plants. This is because they may be prone to aninfection from any insects or bacteria that may be present on them.
  2. 60. What statement by a visitor indicates adequate understanding of entering the room of a client on neutropenicprecautions?1. “I can bring fresh flowers.”2. “I can bring a fruit basket.”3. “I need to wash my hands.”4. “I do not wear a mask.”
    (3) Hand washing is the most important way to prevent the spread of infection. Visitors are allowed but need to observeneutropenic precautions, which the other options do not indicate.
  3. 61. Which statement by the nurse best indicates empathy when talking to a client on neutropenic precautions?1. “Tell me how it feels for you to be in this room alone so much.”2. “This must be a nice break for you to have some time alone.”3. “This probably makes you nervous to be here alone.”4. “I wish I had some time like this to be alone by myself.”
    (1) This open-ended statement allows the client to vent feelings and indicates empathy by the nurse. The other statementsmake unwarranted assumptions, or are insensitive.
  4. 62. A client received testing and was just informed she has leukemia. Which statement by the nurse is mosttherapeutic?1. “We have treatments for leukemia that are quite effective.”2. “Don’t worry, because your type of leukemia is treatable.”3. “Lots of people have leukemia and are successfully treated.”4. “How does it feel for you to hear you have leukemia?”
    (4) This statement is most therapeutic, as it allows the client to ventilate her feelings. The ability of the nurse to be presentwith the client during this difficult time demonstrates caring for the client. The other statements may offer falsehope and do not give the client the opportunity to share her feelings.
  5. 63. An Italian client who is Catholic has just learned that he has leukemia. He asks the nurse to call a priest for him.Which of the following is an appropriate response by the nurse?1. “Wouldn’t you rather speak to a Methodist preacher?”2. “The call can wait until tomorrow.”3. “I am Baptist, so I cannot call a priest for you.”4. “I will contact a priest for you right away.”
    (4) This statement reveals cultural awareness and the importance of spirituality in the healing process. The other statementsshow lack of sensitivity to the client’s spiritual needs.
  6. 64. Which of the following statements by a client being treated for iron-deficiency anemia with iron tabletsindicates ability to care for himself?1. “I will need to have my blood checked regularly.”2. “I can hold my iron pill if I feel good.”3. “If I feel bad, I’ll wait until my appointment to tell the doctor.”4. “My stool may turn light brown color.”
    indicates ability to care for himself?1. “I will need to have my blood checked regularly.”2. “I can hold my iron pill if I feel good.”3. “If I feel bad, I’ll wait until my appointment to tell the doctor.”4. “My stool may turn light brown color.”(1) The client will likely have blood drawn at regular intervals to check red blood cell (RBC) counts. If iron is prescribed,it should not be held but taken as directed. If the client feels poorly, the doctor should be notified immediately,in case the condition has worsened. The stool will turn a dark black color when the client takes iron.
  7. 65. Which medication may impair platelet aggregation?1. Lisinopril (Zestril)2. Protonix (Pantoprazole)3. Dipyramidole (Persantine)4. Metformin (Glucophage)
    (3) Dipyramidole may impair platelet aggregation, not the other medications.
  8. 66. A client with which of the following conditions may receive a unit of platelets?1. diverticulosis2. asthma3. prostatitis4. lymphoma
    (4) A client with lymphoma may have a decreased platelet count that warrants receiving platelets. This is not true ofthe other conditions.
  9. 67. Which of the following terms refers to removal of an entire lung?1. thoracotomy2. pneumonectomy3. lobectomy4. decortication
    2) Pneumonectomy refers to removal of an entire lung, not the remaining pulmonary surgical terms.
  10. 68. Which of the following findings indicates a flail chest?1. tracheal deviation to the affected side2. tracheal deviation to the unaffected side3. multiple rib fractures on one side4. paradoxical movement of the chest
    (4) Paradoxical movement of the chest indicates a flail chest, not the other findings. Multiple rib fractures do not necessarilycreate a flail chest. There is no tracheal deviation with flail chest.
  11. 69. Which structure of the heart is enlarged in the client with cor pulmonale?1. right atrium2. left atrium3. right ventricle4. left ventricle
    (3) The right ventricle is enlarged in the client with cor pulmonale, not the other cardiac structures.
  12. 70. Which of the following is not a cause of chronic obstructive pulmonary disease (COPD)?1. smoking2. exercise3. infection4. heredity
    (2) Exercise is not a cause of chronic obstructive pulmonary disease; the other options are causes of COPD.
  13. 72. Cystic fibrosis is most commonly found in which cultural group?1. Asian2. Caucasian3. African American4. Native American
    (2) Cystic fibrosis is most commonly found in Caucasians, not the other cultural groups.
  14. 73. Which of the following cultural groups has the highest incidence of thalassemia?1. Asian2. Hispanic3. African American4. Native American
    (3) African Americans have the highest incidence of thalassemia of the listed cultural groups. People of Mediterraneanorigin also have a high incidence of thalassemia.
  15. 74. Which of the following conditions may lead to anemia?1. gastritis2. pneumonitis3. arthritis4. ronsilitis
    (1) Gastritis may lead to anemia, due to blood loss. The other conditions do not typically involve blood loss.
  16. 75. Which of the following signs or symptoms would a client with severe anemia not exhibit?1. bradycardia2. pallor3. tachypnea4. headache
    (4) Liver has high iron content. The other foods do not have high iron content.
  17. 77. By which of the following routes is parenteral iron given?1. intraosseous2. intradermal3. subcutaneous4. intramuscular
    (4) Parenteral iron is given by the intramuscular route, as it can stain tissue. It may also be given intravenously, but notthe other routes listed.
  18. 78. Which of the following surgeries may be performed as treatment for thrombocytopenia?1. laminectomy2. cholecystectomy3. splenectomy4. appendectomy
    (3) A splenectomy may be done as treatment for thrombocytopenia, as a way of increasing the number of platelets incirculation. The other surgeries are not performed for thrombocytopenia.
  19. 79. Systemic hypertension causes hypertrophy of which part of the heart?1. right ventricle2. left ventricle3. right atrium4. left atrium
    (2) The left ventricle becomes hypertrophied with systemic hypertension, not the other parts of the heart.
  20. 80. Which of the following statements by a hypertensive client indicates adequate understanding of a low sodiumdiet?1. “I will eat less potato chips.”2. “I will eat less tomatoes.”3. “I will eat less fish.”4. “I will eat less apples.”
    (1) This statement indicates adequate understanding by a hypertensive client indicates of a low sodium diet, becausepotato chips are high in sodium, not the other options.