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NCLEX-RN Exam Questions - Part 98
1. A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:
A) Forcing the client to attend all unit activities
B) Encouraging the client to discuss why he is so sad
C) Monitoring elimination patterns
D) Providing sensory stimulation
2. A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse - s notes indicated that the client admitted to 'having a few drinks now and then.' He is probably experiencing which of the following?
A) Major psychotic depression
B) Delirium tremens
C) Generalized anxiety disorder
D) Adjustment disorder with mixed features
3. A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
A) Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
B) Avoiding manipulation of the tracheostomy including cuff deflation
C) Reporting any signs of crepitus immediately to the physician
D) Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
4. A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
A) 'I will not drive but ride in the front seat of the car with a seat belt on for my first doctor - s appointment.'
B) 'When I bathe tomorrow morning, I will be very careful not to get soap on my incision.'
C) 'I am allowed to exercise by walking for short periods.'
D) 'Teach my husband about the diet. He - ll be doing all the cooking now.'
5. A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy.His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
A) A blood pressure reading of 130/70 with a 5-lb weight loss
B) No side effects from antihypertensive medication and an accurate pill count
C) No evidence of increased left ventricular hypertrophy on chest x-ray
D) Serum blood levels of the antihypertensive medication within therapeutic range
A) Forcing the client to attend all unit activities
B) Encouraging the client to discuss why he is so sad
C) Monitoring elimination patterns
D) Providing sensory stimulation
2. A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse - s notes indicated that the client admitted to 'having a few drinks now and then.' He is probably experiencing which of the following?
A) Major psychotic depression
B) Delirium tremens
C) Generalized anxiety disorder
D) Adjustment disorder with mixed features
3. A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
A) Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
B) Avoiding manipulation of the tracheostomy including cuff deflation
C) Reporting any signs of crepitus immediately to the physician
D) Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
4. A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge?
A) 'I will not drive but ride in the front seat of the car with a seat belt on for my first doctor - s appointment.'
B) 'When I bathe tomorrow morning, I will be very careful not to get soap on my incision.'
C) 'I am allowed to exercise by walking for short periods.'
D) 'Teach my husband about the diet. He - ll be doing all the cooking now.'
5. A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy.His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
A) A blood pressure reading of 130/70 with a 5-lb weight loss
B) No side effects from antihypertensive medication and an accurate pill count
C) No evidence of increased left ventricular hypertrophy on chest x-ray
D) Serum blood levels of the antihypertensive medication within therapeutic range
1. Right Answer: C
Explanation: (A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.
2. Right Answer: B
Explanation: (A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. (B) Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation.(C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. (D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.
3. Right Answer: B
Explanation: (A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician.(D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
4. Right Answer: C
Explanation: (A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
5. Right Answer: A
Explanation: (A) A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. (B) Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. (C) Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. (D) Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
Explanation: (A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.
2. Right Answer: B
Explanation: (A) Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. (B) Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation.(C) Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. (D) Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.
3. Right Answer: B
Explanation: (A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician.(D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
4. Right Answer: C
Explanation: (A) Postoperatively, clients with major abdominal surgery are instructed to avoid driving, riding in the front seat, and wearing seat belts because any sudden impact may injure a fresh incision. She should ride in back seat without a seat belt. (B) Clients should not sit in the tub and allow the incision to soak in water because this may predispose the client to infection. A short, cool shower would be preferable. Allowing soap to come in contact with the incision would not harm it and is frequently used as postoperative wound care at home on discharge from the hospital. (C) Activity instructions include: avoid sitting for long periods and get exercise by walking. Lifting more than 5 lb of weight is also prohibited. (D) The client must also learn her diet. Her husband cooking is probably a temporary measure unless he did the cooking prior to her hospitalization.A statement such as this may indicate the need for further exploration of feelings regarding her illness, dependence, and self-care expectations.
5. Right Answer: A
Explanation: (A) A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. (B) Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. (C) Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. (D) Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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