nclex 4

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nclex 4
2012-04-13 03:49:45

nclex 4
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  1. 81. Which of the following is a modifiable risk factor for coronary artery disease?1. ethnicity2. obesity3. gender4. age
    (2) Obesity is a modifiable risk factor for coronary artery disease. The other options are risk factors for coronary arterydisease, but they are not modifiable.
  2. 82. Which mnemonic is used to recall information from a client experiencing chest pain?1. ABCDE2. HURTS3. PQRST4. HEART
    (3) P = precipitating events; Q = quality of pain or discomfort; R = radiation of pain; S = severity of pain; T = timing.The other options are not used.
  3. 83. Which of the following mnemonics is used to remember the ten most important treatment elements of stableangina?1. ABCDE2. HURTS3. PQRST4. HEART
    (1) A = aspirin, antianginal therapy; B = Beta-adrenergic blocker, blood pressure; C = cigarette smoking, cholesterol;D = diet, diabetes; and E = education and exercise. The other mnemonics are not used.
  4. 84. Which of the following medications is an angiotensin-converting enzyme inhibitor?1. Nifedipine (Procardia)2. Verapamil (Calan)3. Diltiazem (Cardizem)4. Captopril (Capoten)
    (4) Captopril is an angiotensin-converting enzyme inhibitor. The other options are calcium channel blockers.
  5. 85. Which of the following actions should a nurse do first when she notices that a client with a history of a recentmyocardial infarction shows an elevated T wave on his EKG monitor strip?1. Give aspirin.2. Call for help.3. Check the client.4. Give nitroglycerine.
    (3) The client should be checked first, to assess whether there is any distress. The other actions may be done later.
  6. 86. Which of the following statements by a client indicates adequate understanding of sexual activity after having amyocardial infarction?1. “I will take a cold shower after sex.”2. “I will eat a large dinner right before sex.”3. “I will not have any foreplay before sex.”4. “I will take nitroglycerine before sex.”
    (4) This is the correct statement, as use of nitrates prior to intercourse is effective in decreasing angina. The clientshould avoid hot or cold showers right before or after intercourse. After eating a heavy meal, the client should wait3–4 hours before having intercourse. Foreplay is desirable, as it allows a gradual increase in heart rate prior to orgasm.
  7. 87. Which of the following is a sign or symptom of digitalis toxicity?1. diaphoresis2. nausea3. pallor4. fruity breath
    (2) Nausea is a symptom of digitalis toxicity, not the other options.
  8. 88. Which medication is used for the management of the client with acute pulmonary edema to decrease preloadand afterload, as well as minimize anxiety?1. Hydrocortisone2. Aminophylline3. Heparin sodium4. Morphine sulfate
    (4) Morphine sulfate is used for the management of the client with acute pulmonary edema to decrease preload andafterload, as well as minimize anxiety, not the other medications.
  9. 89. A client’s EKG strip shows a PR interval of .28 seconds. The nurse should draw what conclusion?1. This is a normal PR interval.2. This is a short PR interval.3. This is a long PR interval.4. This is a peaked PR interval.
    (3) The normal PR interval is .12–.20 seconds.
  10. 90. A client has a heart rate of 40 beats/minute. The nurse knows the rhythm is being conducted from what area ofthe heart?1. SA node2. AV junction3. purkinje fibers4. right atrium
    (2) AV junction conducted rates are 40–60 beats/minute, not the other options.
  11. 91. For the client with pulseless electrical activity due to hypovolemia, which of the following actions should thenurse do first?1. Administer IV fluids.2. Administer defibrillation.3. Administer atropine.4. Administer epinephrine.
    (1) Administering IV fluids should be done first for the client with pulseless electrical activity due to hypovolemia. Theother interventions may be done later, depending on the client’s situation.
  12. 92. For the client in asystole, which of the following actions should the nurse do first?1. Administer oxygen.2. Give IV fluids.3. Give epinephrine.4. Intubate the patient.
    (4) The patient should be intubated first (Airway, Breathing, Circulation). The other actions may be taken afterward.
  13. 164. Which medication would be used to decrease a chemotherapy client’s nausea and vomiting?1. Dexamethasone (Decadron)2. Methylcellulose (Citrucel)3. Phentolamine mesylate (Regitine)4. Metoclopramide (Reglan)
    (4) Metoclopramide (Reglan) is a cholinergic medication used to prevent the nausea and vomiting associated withchemotherapy and delayed gastric emptying. Phentolamine mesylate (Regitine) is an alpha-adrenergic blocker used fortreating hypertention. Methylcellulase (Citrucel) is a bulk laxative. Dexamethasone (Decadron) is a corticosteroid usedto treat cerebral edema.
  14. 165. A 54-year-old man is admitted to the hospital for a colostomy related to a recent diagnosis of colon cancer.During the preoperative period, what is the most important aspect of this client’s nursing care?1. Assure the client that he will be cured of cancer.2. Assess understanding of the procedure and expectation of bodily appearance after surgery.3. Maintain a cheerful and optimistic environment.4. Keep visitors to a minimum, so that he can have time to think things through.
    (2) False reassurance that everything will be all right is inappropriate. It is a block to therapeutic communication andit discounts the client’s feelings. The client should understand the extent of surgery and type and care of the ostomy.Although a cheerful, optimistic environment is important, it is essential that the client understand the proposed surgicaltreatment. Visitors should not be restricted. Family and friends can provide valuable social support to the client.
  15. 166. A client who is getting radiation asks the nurse why these sores developed in the client’s mouth. What is themost appropriate response?1. “Don’t worry; it always happens with radiation.”2. “Your oral hygiene needs improvement.”3. “It is a sign that the radiation is effective.”4. “The sores result because the cells in the mouth are sensitive to the radiation.”
    (4) Epithelial cells are extremely sensitive to radiation therapy, because of their normally high rate of cell turnover. Theclient deserves an honest, supportive answer.
  16. 167. A client develops stomatitis during the course of radiation therapy. Nursing care for this problem shouldinclude:1. a soft, bland diet.2. restricting fluids to decrease salivation.3. rinsing the mouth every two hours with a dilute mouthwash.4. encouraging the client to drink hot liquids.
    (1) Bland foods of moderate temperature facilitate swallowing and decrease pain. Fluids should be encouraged to keeporal membranes moist and to decrease side effects of chemotherapy. Commercial mouthwashes should be avoided becauseof their alcohol content. The mouth should be rinsed with dilute H2O2 or normal saline solution. Lemon-glycerinswabs should be avoided to prevent excessive drying of the oral mucosa.
  17. 168. The chemotherapeutic agent 5-fluorourcacil (5-FU) is ordered for a client as an adjunct measure to surgery.Which statement about chemotherapy is true?1. It is a local treatment affecting only tumor cells.2. It is a systemic treatment affecting both tumor and normal cells.3. It has not yet been proved an effective treatment for cancer.4. It is often the drug of choice because it causes few if any side effects.
    (2) 5-Fluorouracil (5-FU) is an antineoplastic, antimetabolic drug that inhibits DNA synthesis and interferes with cellreplication. It is given intravenously and acts systemically. It affects all rapidly growing cells, both malignant and normal.It is used as adjunct therapy for treating cancer of the colon, rectum, stomach, breast, and pancreas. This drug hasmany side effects, including bone marrow depression, anorexia, stomatitis, and nausea and vomiting.
  18. 169. Which instruction should be given in a health education class regarding testicular cancer?1. All males should perform a testicular exam after the age of 30.2. Testicular exams should be performed on a daily basis.3. Reddening or darkening of the scrotum is a normal finding.4. Testicular exams should be performed after a warm bath or shower.
    (4) Testicular exams should be performed after a warm shower or bath to relax the scrotum. Testicular exams should bedone by all men beginning at age 15 on a monthly basis. Reddening or darkening of the scrotum is not normal findingand should be reported to a physician.
  19. 170. During surgery, it is found that a client with adenocarcinoma of the rectum has positive peritoneal lymphnodes. What is the next most likely site of metastasis?1. brain2. bone3. liver4. mediastinum
    (3) Colon tumors tend to spread through the lymphatics and portal vein to the liver. Although metastasis to the othersites listed is possible, the liver is most likely the first to be affected.
  20. 171. Medical treatment for a client with cervical cancer will include a hysterectomy followed by internal radiation.Although she is 32 years old and has three children, the client tells the nurse that she is anxious regarding theimpending treatment and loss of her femininity. Which interaction is most appropriate?1. Tell the client that now she does not have to worry about pregnancy.2. Provide the client with adequate information about the effects of treatment on sexual functioning.3. Refer her to the physician.4. Avoid the question. Nurses are not specialists in providing sexual counseling.
    (2) Many women with cervical cancer fear a loss of femininity. It is important to discuss the effects of treatment to enablethe client to prepare for changes in sexual functioning. Although telling the client that she does not have to worry aboutpregnancy is accurate, it is not a therapeutic response. Nurses are capable of answering questions regarding sexuality. Theclient will need to be referred to other resources if the client’s concerns cannot be addressed by the nurse; the physicianshould be notified of the client’s concerns, but not necessarily as a referral.
  21. 172. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of acervical implant is:1. creamy, pink-tinged vaginal drainage.2. stomatitis.3. constipation.4. xerostomia.
    (1) Vaginal drainage will persist for 1–2 months after removal of a cervical implant. Diarrhea, not constipation, is usuallya side effect of cervical implants; stomatitis and xerostomia are local side effects of radiation to the mouth.
  22. 173. A client’s care plan during the time that she has a cervical implant in place would include with intervention?1. frequent ambulation2. unlimited visitors3. low-residue diet4. vaginal irrigations every shift
    (3) Clients with cervical implants require a low-residue diet (and often antidiarrheal medications) to reduce the frequencyof defecation. Defecation may cause accidental dislodgement of the implant from straining and sitting on a bedpan.Frequent ambulation is contraindicated because it will dislodge the implant. Bed rest in a supine or low Fowler’s positionshould be maintained. Visitors should be limited to one 15-minute visit a day, and no pregnant women or children shouldbe allowed because of the radiation exposure. Vaginal irrigations are contraindicated during this period of time.
  23. 174. Which finding is a long-term side effect of a cervical radium implant?1. shortening and narrowing of the vagina2. nausea3. uterine cramping4. diarrhea
    (1) Shortening and narrowing of the vagina is a distressing long-term complication of cervical implants. Women needto use a vaginal dilator twice a week to stretch the tissue. Uterine cramping is a temporary side effect that occurs only ifthe implant extends into the uterus. Nausea and diarrhea may occur during the initial treatment but are not long-termside effects.
  24. 175. When a client is having external radiation for lung cancer, what side effect is most likely to be experienced?1. alopecia2. bone marrow suppression3. stomatitis4. dyspnea
    (4) The majority of side effects of external radiation are dependent on the specific site being radiated. Because theclient’s cancer site is the lung, radiation will result in irritation of the lung mucosa, resulting in dyspnea.
  25. 176. Nursing management of a client’s irradiated skin will not include which of the following?1. applying A and D Ointment prn to relieve dry skin between treatments2. cleansing the skin with tepid water and a soft cloth3. avoiding direct exposure to the sun4. redrawing the skin markings if they are accidentally removed
    (4) Skin markings must not be removed in any way. If they are inadvertently washed off, markings are redrawn only bythe radiation technician.
  26. 177. A 25-year-old male client receiving external radiation treatments tells you that he fears he is radioactive and adanger to his family and friends. How would the nurse dispel his fears?1. Inform him that radiation machines are risk free.2. Explain that once the machine is off, radiation is no longer emitted.3. Avoid telling him that his fears are in fact true.4. Instruct him to spend short periods of time with his family and friends.
    (2) It is important to understand the difference between external and internal radiation so that the nurse can be accuratewhen correcting the client’s misconceptions. He is not radioactive and does not need to limit contact with others.
  27. 178. The nurse assesses for findings of early cervical cancer by which of the following?1. a dark, foul-smelling vaginal discharge2. pressure on the bladder or bowel, or both3. back and leg pain and weight loss4. vaginal discharge (leucorrhea)
    (4) The two chief symptoms of cancer of the cervix are metrorrhagia (vaginal bleeding or spotting at irregular intervalsand between periods) and a watery vaginal discharge.
  28. 179. The nurse discusses with a client in the healthcare clinic the possibility of endometrial cancer. Which of thefollowing statements is incorrect concerning endometrial cancer?1. Diagnosis is most frequently established by a dilation and curettage (D&C).2. Prolonged use of exogenous estrogen increases the occurrence.3. The first and most important symptom is abnormal bleeding.4. This malignancy tends to spread rapidly to other organs.
    (4) Cancer of the endometrium tends to be slow spreading. After it has spread to the cervix, invaded the myometrium,or spread outside the uterus, the prognosis is poor.
  29. 180. The Pap smear reveals that a client has cancer of the cervix. The mode of treatment is an abdominalhysterectomy. The client voices concern about undergoing menopause. In counseling her, which statementwould be most appropriate?1. A surgical menopause will occur, and treatment with estrogen therapy will be necessary.2. The ovaries will continue to function and produce estrogen, thus preventing menopause as a result ofsurgery.3. Ovarian hormone secretion ceases, but the hypothalamus will continue to secrete FSH, and this preventsmenopause.4. The ovaries will cease functioning, and it will be necessary to take estrogen.
    (2) Menstruation will cease after a hysterectomy, but as long as the ovaries are left in place, they will continue to function,and surgical menopause will not occur. A hysterectomy is removal of the uterus and usually the cervix.
  30. 181. Which of the following statements is true about lead-poisoning?1. The child suffering from acute lead intoxication presents a medical emergency.2. It is hard to detect since lead is normally present in the blood.3. It is a silent disease, because there are no warning signs or chronic symptoms.4. None of the above.
    (1) A toxic condition caused by ingestion or inhalation of lead or lead compounds; the acute form of intoxication ischaracterized by a burning sensation in the mouth and esophagus, colic, constipation, or diarrhea, mental disturbances,and paralysis of the extremities, followed in severe cases by convulsions and muscular collapse. If ingested, treatment commences with gastric lavage with magnesium or sodium sulfate, fluid therapy followed by chelation with IM injectionof calcium disodium edentate, or for severe cases, British antilewisite. Encephalopathy must be anticipated in childrenwith lead poisoning.