NCLEX 4

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NCLEX 4
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2011-06-24 07:43:00
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NCLEX 4
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  1. 1. Evaluation of successful resolution of a fluid volume deficit may be demonstrated by which
    • of the following?
    • 1. The client demonstrates an absence of postural hypotension and tachycardia
    • 2. The client adheres to prescribed dietary sodium restrictions
    • 3. The client maintains weight loss
    • 4. The client maintains a serum Na above 145 mEq
  2. 2. Ms. Stone is admitted with a serum magnesium deficit. Assessment reveals a positive
    • Trousseau’s and Chvostek’s signs. Which of the following nursing diagnosis would be most
    • appropriate?
    • 1. High risk for injury R/T increased neuromuscular irritability
    • 2. High risk for injury R/T fractures secondary to loss of calcium
    • 3. Fluid volume deficit R/T dehydration
    • 4. Activity intolerance R/T skeletal muscle weakness
  3. 3. Ms. Fair is a 77-year-old female. Her husband reports that she has had a poor appetite over
    • the past two weeks, with occasional nausea and vomiting. When placed on a cardiac monitor
    • various abnormal heart beats are noted. Based on this data, the nurse would suspect that Ms.
    • Fair is experiencing.
    • 1. Hyponatremia
    • 2. Hypermagnesemia
    • 3. Hypercalcemia
    • 4. Hypokalemia
  4. 4. The nurse is caring for a thoracotomy client, one day post operative on 40% humidified
    • oxygen. ABG results are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on this information,
    • which of the following nursing actions would be best?
    • 1. Position in high fowlers and encourage coughing, deep breathing, evaluate airway
    • patency
    • 2. Place in prone position and request respiratory therapy to perform postural drainage and
    • percussion therapy
    • 3. Call the doctor and advise him of the ABGs; anticipate increase in oxygen percentage
    • 4. Administer anti-anxiety agent and assist the client with a rebreathing device to increase
    • oxygen levels
  5. 5. It is 0600 and a client is scheduled for a cardiac catheterization at 0800. Laboratory work
    • completed five days ago showed: K 3.0 mEq/L, Na 148 mEq/L, glucose 178 mg/dL. He
    • complains of muscle weakness and cramps. Which nursing action should be implemented at
    • this time?
    • 1. Hold 0700 dose of spironolactone (Aldactone®)
    • 2. Encourage eating bananas for breakfast
    • 3. Call the physician to suggest a stat K level
    • 4. Call for a twelve lead ECG
    • Burns
  6. 6. A client is admitted to the ER with second and third degree burns to her anterior chest, both
    • arms, and right leg. Priority information to determine at the time of admission would include
    • which of the following?
    • 1. Percentage of burned surface area
    • 2. Amount of IV fluid necessary for fluid resuscitation
    • 3. Any evidence of heat inhalation or airway problems
    • 4. Circumstances surrounding the burn and contamination of the area
    • 7. A family member of a client who has sustained an electrical burn states, “I don’t understand
    • why he has been here a week, the burn doesn’t look that bad.” The nurse’s response would be
    • based on which of the following?
    • 1. Electrical burns are more prone to infections
    • 2. Electrical burns are always much worse than they look on the outside
    • 3. Cardiac monitoring is important since burns always affect cardiac function
    • 4. Electrical burns can be dececlientive as underlying tissue is damaged
    • 8. A client has severe second and third degree burns over 75 percent of his body. Which
    • assessment finding indicates an early problem with shock?
    • 1. Epigastric pain and seizures
    • 2. Widening pulse pressure and bradycardia
    • 3. Cool and clammy skin and tachypnea
    • 4. Kussmaul respirations and lethargy
    • 9. During a first aid class, the nurse is instructing clients on the emergency care of second
    • degree burns. Which of the following interventions for second degree burns of the chest and
    • arms will best prevent infection?
    • 1. Wash the burn with an antiseclientic soap and water
    • 2. Remove soiled clothing and wrap victim in a clean sheet
    • 3. Leave blisters intact and apply an ointment
    • 4. Do nothing until the victim arrives in a burn unit.
    • Oncology
    • 10. To promote safety in the care of a client receiving internal radiation therapy the nurse
    • would:
    • 1. Restrict visitors who may have an upper respiratory infection
    • 2. Assign only male care givers to the client
    • 3. Plan nursing activities to decrease nurse exposure
    • 4. Wear a lead lined apron whenever delivering client care
    • 11. Which of the following measures should the nurse take while a client has a radium
    • implant
    • for the treatment of uterine cancer?
    • 1. Evaluate the position of the applicator every two hours
    • 2. Place on a low residue diet to decrease bowel movements
    • 3. Encourage the use of the bedside commode every 1-2 hours
    • 4. Decrease fluid intake to decrease radiation in bladder
    • 12. A client with lung cancer and bone metastasis is grimacing and states, “I am a little
    • uncomfortable, may I have something for pain?” Which of the following should the nurse do
    • first before administering pain medication?
    • 1. Check the chart to determine last medication
    • 2. Encourage client to refocus on something pleasant
    • 3. Notify doctor that medication is not working
    • 4. Assess the severity and location of pain
    • 13. A client on chemotherapy has a WBC count of 1200 mm. Based on this data, which of the
    • following nursing actions should the nurse take first?
    • 1. Check temperature q4h
    • 2. Monitor urine output
    • 3. Assess for bleeding gums
    • 4. Obtain an order for blood cultures
    • 14. A client is admitted to the outclient unit in the Cancer Center for his chemotherapy. He is
    • lethargic, weak, and pale. His WBC count is 3000. Which of the following nursing
    • interventions would be most important for the nurse to implement?
    • 1. Establish emotional support
    • 2. Position for physical comfort
    • 3. Maintain respiratory isolation
    • 4. Hand washing prior to care
    • 15. Which of the following properly stated nursing diagnoses would be a priority for a 65-yearold
    • client immediately after her modified radical mastectomy and axillary dissection?
    • 1. Anxiety related to the mastectomy
    • 2. Skin integrity, impairment of, related to mastectomy
    • 3. Alteration in comfort related to incisional pain
    • 4. Self-care deficit related to dressing changes
    • 16. A client had a radical mastectomy for cancer in her right breast. After she returns to your
    • unit, which of the following would be the most appropriate for her?
    • 1. Left side with right arm protected in a sling
    • 2. Right side with right arm elevated
    • 3. Semi-fowlers position with right arm elevated
    • 4. Prone position with right arm elevated
    • 17. A client with prostatic cancer is admitted to the hospital with neutropenia. Which signs and
    • symclientoms are most important for the nurse to report to the next shift?
    • 1. Arthralgia and stiffness
    • 2. Vertigo and headache
    • 3. General malaise and anxiety
    • 4. Temperature elevation and lethargy
    • 18. A 32-year-old male with acute lymphocytic leukemia (ALL) is admitted with shortness of
    • breath, anemia, and tachycardia. Based on this nursing assessment, the most appropriately
    • stated nursing diagnosis would be:
    • 1. Altered protection, immunosuppression: Leukemia
    • 2. Impaired gas exchange related to decreased RBCs
    • 3. Potential for infection related to altered immune system
    • 4. Potential injury to decreased platelets
    • Endocrine
    • 19. A client is admitted with diabetic ketoacidosis. You note his respiratory rate to be 38.
    • Considering his condition you are aware that this increased rate is a result of:
    • 1. An effort by the body to compensate for respiratory acidosis
    • 2. An effort by the body to remove excess acid from the body
    • 3. An effort by the body to supply more oxygen to the depleted tissues
    • 4. An effort by the body to conserve CO2
    • 20. The client is admitted with acute hypoparathyroidism. To maintain client safety, which item
    • is most important to have available?
    • 1. Tracheostomy set
    • 2. Cardiac monitor
    • 3. IV monitor
    • 4. Heating pad
    • 21. To evaluate for the desired response of calcium gluconate in treating acute
    • hypoparathyroidism the nurse would monitor the client most closely for:
    • 1. Intake and output
    • 2. Confusion
    • 3. Tetany
    • 4. Bone deformities
    • 22. Which symclientom is most important for the nurse to report to the next shift about the
    • client with hyperparathyroidism?
    • 1. Abdominal discomfort
    • 2. Hematuria
    • 3. Muscle weakness
    • 4. Diaphoresis
    • 23. The nurse would caution the client with hypothyroidism about avoiding:
    • 1. Warm environmental temperatures
    • 2. Narcotic sedatives
    • 3. Increased physical exercise
    • 4. Numbness and tingling of fingers
    • 24. In planning care for the client with hyperthyroidism, the nurse would anticipate the client to
    • require:
    • 1. Extra blankets for warmth
    • 2. Ophthalmic drops on a regular basis
    • 3. Increased sensory stimulation
    • 4. Frequent low calorie snacks
    • 25. The elderly client with hyperparathyroidism should be cautioned about:
    • 1. Pathological fractures
    • 2. Decreasing fluid intake
    • 3. Tetany and tingling of fingers
    • 4. Increasing physical activity
    • 26. The nurse is aware that which of the following statements made by the client indicates a
    • correct understanding of steroid therapy for Addison’s Disease?
    • 1. “I’ll take the medicine in the morning because if I take it at night it might keep me
    • awake.”
    • 2. “I’ll take the same amount from now on.”
    • 3. “I’ll increase my potassium by eating more bananas.”
    • 4. “I’ll be eating foods low in carbohydrates and salt.”
    • 27. Which nursing action has the highest priority in caring for the client with
    • hypoparathyroidism?
    • 1. Develop a teaching plan
    • 2. Plan measures to deal with cardiac arrhythmias
    • 3. Take measures to prevent a respiratory infection
    • 4. Assess laboratory results
    • 28. A client is going to have a parathyroidectomy. Which of the following foods would the
    • nurse discourage the client from eating?
    • 1. Milk products
    • 2. Green vegetables
    • 3. Seafood
    • 4. Poultry products
    • 29. Which of the following types of foods would the nurse encourage the client with
    • hypoparathyroidism to eat?
    • 1. High phosphorus
    • 2. High calcium
    • 3. Low sodium
    • 4. Low potassium
    • 30. A client is admitted for a series of tests to verify the diagnosis of Cushing’s syndrome.
    • Which of the following assessment findings would support this diagnosis?
    • 1. Buffalo hump, hyperglycemia, and hypernatremia
    • 2. Nervousness, tachycardia, and intolerance to heat
    • 3. Lethargy, weight gain, and intolerance to cold
    • 4. Irritability, moon face, and dry skin
    • 31. One hour after receiving 7 units of regular insulin, the client presents with diaphoresis,
    • pallor, and tachycardia. The priority nursing action would be:
    • 1. Notify the doctor
    • 2. Call the lab for a blood glucose level
    • 3. Offer the client milk and crackers
    • 4. Administer GlucagonÒ
    • 32. A client was admitted for regulation of her insulin. She takes 15 units of HumulinÒ insulin
    • at 8:00 a.m. every day. At 4:00 p.m., which of the following nursing observations would
    • indicate a complication from the insulin?
    • 1. Acetone odor to the breath, polyuria, and flushed skin
    • 2. Irritable, tachycardia, and diaphoresis
    • 3. Headache, nervousness, and polydipsia
    • 4. Tenseness, tachycardia, and anorexia
    • 33. A client received regular insulin, 6 units, 3 hours ago. Which of the following assessments
    • would be most important to report to the next shift?
    • 1. Kussmaul’s respirations and diaphoresis
    • 2. Anorexia and lethargy
    • 3. Diaphoresis and trembling
    • 4. Headache and polyuria
    • Cardiovascular
    • 34. A client with sudden onset of deep vein thrombosis is started on a heparin IV drip. Which of
    • the following additional orders should the nurse question?
    • 1. Cold wet packs to the affected leg
    • 2. Elevate foot of bed six inches
    • 3. Commode privileges without weight-bearing
    • 4. Elastic Stockings on unaffected leg
    • 35. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg.
    • Which of the following would be an appropriate nursing goal for this client?
    • 1. To decrease inflammatory response in the affected extremity and prevent emboli
    • formation
    • 2. To increase peripheral circulation and oxygenation of affected extremity
    • 3. To prepare client and family for anticipated vascular surgery on affected extremity
    • 4. To prevent hypoxia associated with the development of pulmonary emboli
    • 36. Which of the following signs indicate effective CPR?
    • 1. Adequate capillary refill
    • 2. Normal skin color
    • 3. Symmetrically dilated pupils
    • 4. Palpable carotid pulse
    • 37. A permanent demand pacemaker set at a rate of 72 is implanted in a client for persistent
    • third degree block. Which of the following nursing interventions would indicate a
    • pacemaker dysfunction?
    • 1. Pulse rate of 88 and irregular
    • 2. Apical pulse rate regular at 68
    • 3. Blood pressure of 110/80, pulse of 78
    • 4. Tenderness at site of pacemaker implant
    • 38. A client with an irregular pulse rate of 181 and a K level of 3.0 mEq/L has Lanoxin®
    • ordered. The nurse should:
    • 1. Give the digoxin since the pulse is within normal limits
    • 2. Holds the digoxin since the pulse is irregular
    • 3. Call the doctor to report the potassium
    • 4. Hold the digoxin since toxicity occurs with high potassium levels
    • 39. The nurse has administered sublingual nitroglycerin (Nitrostat®) to a client complaining of
    • chest pain. Which of the following observations is most important for the nurse to report to
    • the next shift?
    • 1. The client indicates the need to use the bathroom
    • 2. Blood pressure has decreased from 140/80 to 90/60
    • 3. Respiratory rate has increased from 16 to 24
    • 4. The client indicates the chest pain has subsided
    • 40. A 72-year-old client has an order for digoxin (Lanoxin®) 0.25 mg PO in the morning. The
    • nurse reviews the following information:
    • apical pulse: 68
    • respirations: 16
    • plasma digoxin level: 2.2 ng/ml
    • Based on this assessment, which nursing action is appropriate?
    • 1. Give the medication on time
    • 2. Withhold the medication, notify the physician
    • 3. Administer epinephrine 1:1000 stat
    • 4. Check the client’s blood pressure
    • 41. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
    • want to make sure you have the most up to date material so that you can pass your boards
    • the first time.
    • Respiratory
    • 42. When obtaining a specimen from a client for sputum culture and sensitivity which of the
    • following instructions would be best?
    • 1. After pursed lip breathing cough into container
    • 2. Upon awakening cough deeply and expectorate into container
    • 3. Save all sputum for 3 days in covered container
    • 4. After respiratory treatment expectorate into container
    • 43. Which of the following is the most effective method for the nurse to evaluate the
    • effectiveness of tracheal suctioning?
    • 1. Note subjective data such as, “My breathing is much improved now.”
    • 2. Note objective findings such as decreased respiratory rate and pulse
    • 3. Consult with respiratory therapy to determine effectiveness
    • 4. Auscultate the chest for change or clearing in adventitious breath sounds
    • 44. After a bronchoscopy is completed with a client, which of the following nursing
    • observations would indicate a complication?
    • 1. Depressed gag reflex
    • 2. Sputum streaked with blood
    • 3. Tachypnea
    • 4. Widening pulse pressure
    • 45. The nurse is caring for a client with pneumonia. Which of the following nursing
    • observations would indicate a therapeutic response to the treatment for the infection?
    • 1. Oral temperature of 101ºF, increased chest pain with non-productive cough
    • 2. Cough productive of thick green sputum, client state he feels tired
    • 3. Respirations at 20, with no complaints of dyspnea, moderate amount of thick white
    • sputum
    • 4. White cell count of 10,000 mm, urine output at 40 ml/hr, decreasing amount of sputum
    • 46. During the shift report, a client’s ventilator alarm is activated. Which action would the nurse
    • implement first?
    • 1. Notify the respiratory therapist
    • 2. Check the ventilator tubing for excess fluid
    • 3. Deactivate the alarm and check the spirometer
    • 4. Assess the client for adequate oxygenation
    • 47. The nurse is caring for a client who has a 5 year history of chronic lung disease. The nursing
    • assessment reveals a severely dyspneic client, pulse at 140, respirations labored, and
    • slightly cyanotic. An appropriate nursing action to relieve the client’s dyspnea would
    • include:
    • 1. Administer oxygen at 40% heated mist
    • 2. Assist the client to cough and deep breathe
    • 3. Elevate the head of the bed, low flow oxygen
    • 4. Position the client prone and assess breath sounds
    • 48. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
    • want to make sure you have the most up to date material so that you can pass your boards
    • the first time.
    • 49. The nurse is caring for a client who has been immobilized for three days following a
    • perineal prostatectomy. The client begins to experience sudden shortness of breath, chest
    • pain, and coughing with blood-tinged sputum. Immediate nursing actions would include:
    • 1. Elevate the head of the bed, begin oxygen, assess respiratory status
    • 2. Assist the client to cough, if unsuccessful then perform nasotracheal suctioning
    • 3. Position in supine position with legs elevated; monitor CVP closely
    • 4. Administer morphine for chest pain; obtain a 12 lead ECG to evaluate cardiac status
    • 50. Your client becomes extubated while being turned. He is cyanotic and has bradycardia and
    • arrhythmias. Which action would be the highest priority while waiting for a physician to
    • arrive?
    • 1. Immediately begin CPR
    • 2. Increase the IV fluids
    • 3. Provide oxygen by ambuing and maintaining the airway
    • 4. Prepare the medication for resuscitation
    • Orthopedic
    • 51. A client had a below-the-knee amputation due to problems with gangrene. During the first 2
    • hours after surgery which nursing action would be most important?
    • 1. Notify the doctor of a small amount of serosanguineous drainage
    • 2. Elevate the stump on a pillow to decrease edema
    • 3. Maintain the stump flat on the bed by placing the client in the prone position
    • 4. Do passive range of motion TID to the unaffected leg
    • 52. A client is admitted with a fractured right hip. The doctor writes an order for Buck’s
    • traction. In planning care for a client in Buck’s traction, the nurse would:
    • 1. Turn the client every two hours to the unaffected side
    • 2. Maintain client in a supine position
    • 3. Encourage client to use a bedside commode
    • 4. Prevent foot drop by placing a foot board to the bed
    • 53. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
    • want to make sure you have the most up to date material so that you can pass your boards
    • the first time.
    • 54. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a
    • walker. In planning nursing care, which statement by the nurse will best help this client?
    • 1. Sit in a low chair for ease in getting up in the walker
    • 2. Make sure rubber caps are present on all 4 legs of the walker
    • 3. Begin weight-bearing on the affected hip as soon as possible
    • 4. Practice tying your shoes before using the walker
    • 55. To prevent neurological complications for a pre-school client with a full-leg cast, the nurse
    • would schedule regular checks of:
    • 1. Femoral pulses
    • 2. Levels of consciousness
    • 3. Blood pressure readings
    • 4. Sensory testing of affected foot
    • 56. A teenager has had a repair of an open compound fracture of the tibia and fibula. An
    • external fixation device has been applied to stabilize the fracture. Before administering pin
    • site care, the nurse should check which of the following?
    • 1. Correct alignment
    • 2. Appearance of pin sites
    • 3. Tightness of screws
    • 4. Vital signs
    • 57. Which nursing assessment suggests a complication of a plaster of paris cast application to
    • the arm?
    • 1. The client states that the wet cast feels “warm”
    • 2. The client is able to move his fingers and thumb freely
    • 3. The client states that his little finger feels “asleep”
    • 4. The wet cast appears gray and smells slightly musty
    • Renal
    • 58. In planning the diet teaching for a child in the early stage of nephrotic syndrome, the nurse
    • would discuss with the parents the following dietary changes:
    • 1. Adequate protein intake, low sodium
    • 2. Low protein, low potassium
    • 3. Low potassium, low calorie
    • 4. Limited protein, high carbohydrate
    • 59. Which of the following clients is a likely candidate for developing acute renal failure?
    • 1. A female with recent ileostomy due to ulcerative colitis
    • 2. Middle age male with elevated temperature and chronic pancreatitis
    • 3. Teenager in hypovolemic shock following a crushing injury to the chest
    • 4. Child with compound fracture of right femur and massive laceration to left arm
    • 60. A client is experiencing severe pain from renal calculi. Which of the following is a priority
    • in the nursing care plan?
    • 1. Administer pain medication as often as needed according to doctor’s orders
    • 2. Encourage fluid intake to help flush the stone through
    • 3. Assist the client to ambulate to promote draining the bladder
    • 4. Irrigate the bladder to maintain urinary patency
    • 61. In order to maintain asepsis, the client on home peritoneal dialysis should be taught to:
    • 1. Drink only distilled water
    • 2. Cap the Tenchkoff catheter when not in use
    • 3. Boil the dialysate one hour prior to a pass
    • 4. Clean the arteriovenous fistula with hydrogen peroxide daily
    • 62. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values
    • include BUN 25, K 5.0. Which nutrients should be restricted in this client’s diet?
    • 1. Protein
    • 2. Fats
    • 3. Carbohydrates
    • 4. Magnesium
    • Gastrointestinal
    • 63. A client had surgery for cancer of the colon and a colostomy was performed. Prior to
    • discharge, the client states that he will no longer be able to swim. The nurse’s response
    • would be based on which of the following?
    • 1. Swimming is not recommended, the client should begin looking for other areas of interest
    • 2. Swimming is not restricted if the client wears a water tight dressing over the stoma
    • 3. The client cannot go into water that is over the stoma area, he can only go into water up
    • to the stoma area
    • 4. There are no restrictions on the activity of a client with a colostomy, all previous
    • activities may be resumed
    • 64. A client who is fourth day post-op appendectomy complains of severe abdominal pain.
    • During the initial assessment he states, “I have had two almost black stools today.” Which
    • nursing action is most important?
    • 1. Start an IV with D5W at 125 ml/hr
    • 2. Insert a nasogastric tube
    • 3. Notify the doctor
    • 4. Obtain a specimen
    • 65. The nurse is caring for a client with a perforated bowel secondary to a bowel obstruction. At
    • the time the diagnosis is made, which of the following would be a priority in the nursing
    • care plan?
    • 1. Maintain the client in a supine position
    • 2. Notify the client’s next of kin
    • 3. Prepare the client for emergency surgery
    • 4. Remove the nasogastric tube
    • 66. A nursing assessment of a client with a hiatal hernia is most likely to reveal?
    • 1. A bulge in the lower right quadrant
    • 2. Pain at the umbilicus radiating down into the groin
    • 3. Burning sensation in mid-epigastric area each day before lunch
    • 4. Awakening at night with heartburn
    • 67. The nurse is caring for a client postoperative ileostomy. Which of the following nursing
    • observations would relate to a postoperative complication?
    • 1. The ileostomy does not require daily irrigations to maintain function
    • 2. The stoma appears tight and there is a decreased amount of stool
    • 3. An impaction appears to be forming in the distal anal area
    • 4. A weight gain of 5 pounds related to increased fluid retention
    • Neurological
    • 68. The client has been lethargic, but responding to verbal commands. The nurse now assesses
    • that the client is responding by withdrawing to noxious stimuli. The most appropriate
    • nursing action would be:
    • 1. Plan on reassessing the client in one hour
    • 2. Notify the doctor that the client is deteriorating
    • 3. Place the client in Trendelenburg position
    • 4. Call the family and tell them the client is improving
    • 69. The nurse enters the room and discovers the client has right sided paralysis, and unequal
    • pupils. The most appropriate next step for the nurse is to:
    • 1. Call the doctor
    • 2. Assess the respiratory status
    • 3. Determine the level of consciousness
    • 4. Perform a complete neurological evaluation
    • 70. A client is one week post cerebrovascular accident. The nurse notes the client does not
    • respond readily to movement or objects in peripheral fields. Based on this nursing
    • assessment, an appropriate nursing diagnosis is:
    • 1. Impaired adjustment
    • 2. Ineffective individual coping
    • 3. Sensor-perceclientual alteration
    • 4. Self-care deficit
    • 71. The client is transferred to the Neuro Unit after developing right sided paralysis and aphasia.
    • Which of the following should be included in the nursing care plan in order to promote
    • communication with the client?
    • 1. Encourage client to shake head in response to questions
    • 2. Speak in a loud voice during interactions
    • 3. Speak using phrases and short sentences
    • 4. Encourage the use of radio to stimulate the client.
    • 72. What would be the most appropriate next action for the nurse to take after noting the sudden
    • appearance of a fixed and dilated pupil in the neuro client?
    • 1. Re-assess in 5 minutes
    • 2. Check client’s visual acuity
    • 3. Lower the head of the client’s bed
    • 4. Call the doctor
    • 73. Which instruction would be included in planning care for a client with signs of increased
    • intracranial pressure?
    • 1. Encourage coughing and deep-breathing to prevent pneumonia
    • 2. Suction airway every 2 hours to remove secretions
    • 3. Position the client in the prone position to promote venous return
    • 4. Determine cough reflex and ability to swallow prior to administering PO fluids.
    • 74. A client with a closed head injury begins to vomit. Which assessment is the most important
    • for the nurse to report when calling the physician?
    • 1. Increasing lethargy
    • 2. Heart rate of 80
    • 3. Sodium level of 145
    • 4. Presence of facial symmetry
    • 75. The nurse is observing a client for complications following a craniotomy. The client begins
    • complaining of thirst and fatigue. Which nursing observation is most important to report to
    • the physician?
    • 1. Specific gravity of urine is increased, urine is foul smelling
    • 2. Fluid intake over past 24 hours has been 3000 ml
    • 3. Urine output in excess of 4000 ml in 24 hours
    • 4. Presence of diarrhea and excoriation of anal area
    • EENT
    • 76. A client with glaucoma has experienced severe restriction of peripheral vision. He asks the
    • nurse if his vision will get better. The nurse’s best response would be based on which of the
    • following?
    • 1. If he maintains his medications and reduces the pressure, his vision will improve
    • 2. The current damage to vision is permanent, maintaining his eye drops will prevent
    • further damage
    • 1. After the acute episode, surgery will be scheduled to remove his lens
    • which will
    • increase vision
    • 4. After the pressure is stabilized, the doctor will reevaluate his vision and prescribe
    • glasses to correct his vision
    • 77. An adult male client complains of loss of hearing while irrigating his ear to remove cerumen
    • for better observation of the tympanic membrane. The client comments that he is getting
    • dizzy. The nurse would stop the procedure and:
    • 1. Notify the doctor immediately
    • 2. Monitor for changes in intracranial pressure
    • 3. Warm the irrigant and resume the procedure
    • 4. Explore the canal with a cotton applicator
    • 78. The nurse is caring for a client who has just returned to his room after having a scleral
    • buckling procedure done to repair his detached retina. Which of the following is an
    • important nursing action on the operative day?
    • 1. Remove reading material to decrease eye strain
    • 2. Closely assess for presence of nausea and prevent vomiting
    • 3. Assess color of drainage from affected eye
    • 4. Maintain sterility for q3h saline eye irrigations
    • 79. A client has a cataract removed from his left eye. Which of the following is an important
    • nursing intervention in the immediate postoperative period?
    • 1. Position on right side with head slightly elevated
    • 2. Place client on his left side to protect eye
    • 3. Perform sensory neuro checks every 2 hours
    • 4. Maintain complete bed rest for the first 48 hours
    • 80. The nurse is caring for a client with Meniere’s syndrome. The nurse stands directly in front
    • of the client when speaking. Which of the following best describes the rationale for the
    • nurse’s position?
    • 1. This enables the client to read the nurse’s lips
    • 2. The client does not have to turn her head to see the nurse
    • 3. The nurse will have the client’s undivided attention
    • 4. There is a decrease in the client’s peripheral visual field
    • Blood
    • 81. A client is 2 days postoperative aortic aneurysm resection. A complete blood count reveals a
    • decreased red blood cell count. The nursing assessment is most likely to reveal which of the
    • following?
    • 1. Fatigue, pallor, and exertional dyspnea
    • 2. Nausea, vomiting, and diarrhea
    • 3. Vertigo, dizziness and shortness of breath
    • 4. Malaise, flushing, and tachycardia
    • 82. A client who is receiving a blood transfusion is experiencing a hemolytic reaction. The
    • nurse would anticipate which of the following assessment findings to validate this reaction?
    • 1. Hypotension, backache, low back pain, fever
    • 2. Wet breath sounds, severe shortness of breath
    • 3. Chills and fever occurring about an hour after infusion started
    • 4. Urticaria, itching, respiratory distress

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