NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCC, Exams of Nursing

Download NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCC and more Exams Nursing in PDF only on Docsity! NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 08.05 Comprehensive Exit Exam Multiple Choice Identify the choice that best completes the statement or answers the question. 1. The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a common side effect of Dilantin therapy? a. "She is very irritable lately." b. "I have trouble getting her to sleep." c. "Her gums look too big for her teeth." d. "She has gained about 10 pounds in the last six months." ANS: C 2. The prescriber orders tranylcypromine sulfate (Parnate)10 mg twice a day for a client with major depression. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ with hypertension. Which of the following adverse reactions can occur with administration of Capoten? a. Tinnitus. b. Persistent cough. c. Muscle weakness. d. Diarrhea. ANS: B 4. A client who has been taking phenazopyridine (Pyridium) for symptoms of NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: C urethritis and cystitis comes to the clinic because her urine is reddish-orange. Which question should the practical nurse ask to determine if the medication has been effective? a. How much water have you been drinking each day? b. Does the urine color stain your toilet bowl or undergarments? c. Have you had any relief from urinary pain, burning, or urgency? d. Did your urine appear cloudy or have a foul odor on voiding? 5. The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ a. Avoid rapid movements after taking the medication. b. Rest in bed after taking the medication for at least 30 minutes. c. Take the medication with water only. d. Allow at least 1 hour between taking the medicine and taking other. ANS: C 6. A client receives a prescription for an oral opioid analgesic for post- operative pain. Which adverse effect should the nurse monitor for with the client? a. Photosensitivity b. Constipation. c. Decreased heart rate. d. Frequent urination. ANS: B 7. A postoperative client receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 11. The nurse understands that the development of an adverse drug reaction is dependent on which factors? a. Client's age, prior drug reactions, genetic factors, and degree of exposure. b. Client's gender, oral route of administration, and history of atrophic disease. c. Client's age, gender, and genetic factors. d. Genetic factors, prior drug reactions, and client's gender. ANS: A 12. The nurse is working in the pediatric unit and receives a phone order from the doctor for a 10-year-old client who weighs 40 kg. The order is for ceftazidime (Fortaz) 1.5 gm every 8 hours IV. The therapeutic dosage range is 90-150 mg/kg/24 hr. What would be the best nursing action? a. Administer the medication because it is within the therapeutic dosage range. b. Call the doctor to clarify the order because it is outside the therapeutic dosage range. c. Call the hospital pharmacist and ask him or her to calculate the dosage. d. Notify the nursing supervisor and request assistance. ANS: A NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 13. The prescriber orders an IV piggyback of Cefotan 1 gm in 100 mL D5W to run over 30 minutes. The drop factor for the tubing is 10 gtt/mL. At what rate in drops per minute would the nurse run the IV? a. 12. b. 25. c. 33. d. 50. ANS: C 14. At the shift hand-off report, a nurse is told that one of her clients is becoming tolerant to his pain medication. What nursing observation would be in agreement with this conclusion? a. The current medication order, which has previously been effective, is no longer providing adequate pain relief. b. The client becomes irritable and confused before the next scheduled dose of medication. c. Pain medication is being administered every 3 to 4 hours around the clock for adequate pain relief. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ d. The client is sleeping, arouses with physical and verbal stimulation, but is very lethargic. ANS: A 15. The nurse is administering medications to a group of clients. One client is an older adult and hard of hearing. The client seems confused when the nurse asks her to state her name and does not give her name. What is the best nursing action? a. Confirm the name, birth date, and hospital number on the client's armband and administer the medication. b. Request the family that is present to validate the information on the client's medication administration record. c. Determine the cause of the confusion and hearing problem before administering any medication. d. Hold the medication and notify the doctor that the client cannot be safely identified if she cannot state her name. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: D d. Tell the client the name of the medication and explain it has been ordered to help to decrease his anxiety and make him more comfortable. 20. It is 4 pm and the nurse is admitting a client with a fractured femur from the emergency room (ER). The client received 10 mg morphine subcutaneous (subQ) at 11 am in the ER for pain. The client is scheduled for surgery, and no further pain orders have been written. The client is complaining of severe leg pain, and the physician cannot be contacted. The nurse administers 5 mg morphine subQ for the pain, and the client is comfortable within 30 minutes. What is best interpretation of the nurse's action? a. The nurse made an appropriate nursing judgment by giving a lesser amount of the drug. b. The nurse acted correctly because the client was in pain and the doctor could not be contacted. c. The drug had been previously ordered; therefore, the nurse's actions were correct. d. The nurse is legally liable for administering a medication without an order. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: D 21. The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? a. The client receiving linear accelerator radiation therapy for lung cancer. b. The client with a radium implant for cervical cancer. c. The client who has just been administered soluble brachytherapy for thyroid cancer. d. The client who returned from placement of iridium seeds for prostate cancer. ANS: A 22. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? a. The client with Cushing's disease. b. The client with diabetes. c. The client with acromegaly. d. The client with myxedema. ANS: A NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 23. Which of the following would not be considered a violation of the Health Insurance Portability and Accountability Act (HIPAA)? a. Providing client information to an individual who claims to be a family member 2. b. Allowing a student nurse, who is taking care of the client, to make copies of laboratory results. c. Discussing the client's condition on the telephone with a family member who has provided the client information code. d. Reviewing the client's chart with the CEO of the hospital, who is the client's brother-in- law. ANS: C 24. Which of the following most clearly represents a situation of assault? a. In the emergency department, a client is intoxicated and verbally abusive; the nurse tells him she will put him in restraints if he does not quit talking. b. A client is in labor and has not received any medication for pain; she tells the nurse she does not want anything for pain; the nurse administers the pain medication ordered. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: B without written client permission. b. When entering nursing information on the client's chart, nurses should close the chart completely and sign off before leaving the client's room. c. Nurses should contact the client's physician regarding a list of family members who can safely receive client information. d. Nurses should avoid calling a client by name when discussing problems with other health care team members. 28. At approximately 9:00 am, the nurse begins charting. The last entry noted was for 1:00 am that morning, and the night nurse did not sign off on the chart. What is the appropriate action? a. Begin charting on the next line below the last entry, and make a note for the night nurse to make a "late entry" when she comes in tonight. b. Leave what you feel is sufficient space for the night nurse to make her entry when she NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ comes in tonight. c. Enter what you think is the appropriate information and sign her name, indicating with your initials that you made the entry for her. d. Refuse to chart anything on the chart until the night nurse is called to return and complete the charting. ANS: A 29. The nurse is preparing an informed consent document for a client scheduled for surgery. The physician has been to visit the client and has discussed the surgery. When the nurse presents the form to the client for his signature, he is hesitant and says he really does not understand the complications and risks. What is the best nursing action? a. Discuss with the client the type of surgery and the risks common to this type of procedure. b. Tell the client that is not a problem and call the physician to advise him of the situation. c. Tell the client that if he does not understand the surgery and risk factors, then he should NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ cancel the surgery. d. Reassure the client that the physician will be available immediately before surgery to discuss his concerns. ANS: B 30. A 4-year-old child has pain in the right leg caused by a fracture to the femur. During the assessment, the nurse notes that the child has bruises and multiple superficial skin lacerations on both the left and right buttocks. What would be the appropriate documentation of this information? a. Child shows severe trauma to the right and left buttocks. b. Child shows signs of abuse in the form of lacerations on the right and left buttocks. c. Child has lacerations on the right and left buttocks, suggesting possible abuse. d. Child has seven 1½-inch to 3-inch superficial lacerations in various states of healing on left and right buttocks. ANS: D 31. A client has been involved in an accident, does not speak English, is NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ tubes. d. A 40-year-old man who is complaining of chills and painful urination is scheduled for a colon resection in 2 hours. ANS:D 33. A nurse manager has been notified to obtain a bed for a client. Of the following clients, which one would the nurse anticipate being able to transfer to a rehabilitation facility? a. A client who had a myocardial infarction (MI) 2 days ago. She has the following vital signs: blood pressure (BP) 150/94 mm Hg, pulse 84 beats/min and irregular, respiration 28 breaths/min, minimal chest pain. b. A client who underwent an abdominal aortic aneurysm resection 3 days ago. He has the following vital signs: BP 130/88 mm Hg, pulse 88 beats/min, respiration 22 breaths/min, and oral temperature 101° F. He is beginning oral intake without problems. c. A client who has a subdural hematoma. He is lethargic; his pulse is 60 beats/min, BP is NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 150/90 mm Hg, respiration is 28 breaths/min, and temperature is 99° F. d. A client who had abdominal exploratory surgery for a bowel obstruction 4 days ago. He has bowel sounds, is taking fluids orally, has an abdominal Penrose drain, and is continuing to experience abdominal pain. ANS: D 34. After report, the nurse prioritizes care of the following assigned clients. Which client would the nurse see first? a. A client with a leaky colostomy bag. b. A client who will be undergoing lumbar puncture at noon. c. A client receiving packed red blood cells, and the bag is half empty. d. A child in sickle cell crisis with an infiltrated IV. ANS:D 35. A labor and delivery RN has been reassigned, or floated, to a step-down telemetry unit for the afternoon shift. Which clients would reflect the most appropriate assignment for this nurse? a. Client who has had cardioversion and client who was admitted NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ during the night because of possible myocardial infarction (MI). b. Client who had a cardiac catheterization that morning and client admitted for 24- hour observation for first-degree heart block. c. Client who currently has third-degree heart block and client with congestive heart failure who had a hypertensive crisis 48 hours ago. d. Client who had MI 72 hours ago and has increasing premature ventricular contractions (PVCs) and a newly admitted client with paroxysmal onset of atrial fibrillation. ANS:B 36. The RN heading the unit team is assigning clients for care to two RNs and an LVN/LPN and a nursing assistant. The RN would assign which of the following clients to the Licenced Practical/Vocational Nurse (LPN/LVN)? a. An older adult who is receiving IV chemotherapy through a central line and will need a dressing change. b. A male client diagnosed with Type I diabetes who will need dressing changes on several stasis ulcers. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ diagnosed with diabetes mellitus. Which collaborative approach is the best use of interdisciplinary team members? a. Schedule the pharmacist to teach about treatment of hypoglycemia. b. Assign the occupational therapist to teach insulin injection techniques. c. Invite the dietician to discuss the timing of meals and snacks. d. Ask the physical therapist to discuss scheduling physical activity. ANS:C 41. The charge nurse is assessing clients who are currently in labor. It is most important for the pediatric healthcare provider to be present for which delivery? a. 40-week primigravida with hypertension who is receiving magnesium sulfate 2 grams/hour. b. 37-week multipara who is receiving penicillin G 2.5 million units IV for Group B Streptococcus. c. 41-week multipara who is requesting an epidural instead of a local anesthetic for delivery. d. 39-week primigravida with a positive urine drug screen who is receiving antiretroviral therapy NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:A 42. An older female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother's original request, which was executed when she was healthy. What information is best for the nurse to provide? a. The client's original request based on the signed living will for no heroic measures should be followed. b. The family should be guided to support the client's current decision about the ventilator. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: B c. The client's cognitive ability should be evaluated before the use of a ventilator is needed. d. The family should be directed to discuss alternative treatment options with the healthcare provider 43. What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? a. Designate 15 minutes a day to respond to each time-waster. b. Delegate other nursing responsibilities to the team members. c. Schedule specific times on a written calendar to review 2 charts per day. d. Review all records 2 days before the due date to focus on the deadline ANS:C 44. The director of nursing of a long term care facility is developing a quality improvement project for the facility's units and establishes that a goal of the project should be consistent documentation of pain for all residents. Which statement is the best indicator of this goal's achievement? a. All of the nursing staff attend mandatory inservice sessions. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:C 48. A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, who is resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? a. Ignoring the resistance b. Telling the LPN that his noncompliance will be documented in his personnel record c. Confronting the LPN and encouraging him to express his feelings regarding the change d. Telling the LPN that a registered nurse will perform all of the computer documentation if he will document all intake and output and vital signs ANS:C 49. A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? a. Home care NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ b. Speech therapy c. Physical therapy d. Occupational therapy ANS:D 50. A nurse is providing preoperative teaching to a client the night before surgery. The client expresses fear of nausea and vomiting postoperatively from the anesthesia because of a bad experience a few years ago. The nurse’s best response to the client’s concens would be which of the following statements? a. “I understand your concerns and fears. I hope your surgeon discussed that problem with you.” b. “Try not to worry. You will be heavily sedated if that occurs, and you will not remember the feelings.” c. “Nausea and vomiting occur much less frequently now, since we use a more balanced approach to anesthesia.” d. “Let both the surgeon and the anesthesiologist know about your fears of this side effect.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:D 52. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse? a. Is unable to feel sensation in the arms and hands. b. Has flaccid upper and lower extremities. c. Blood pressure is 110/70 and the apical pulse is 62. d. Respirations are shallow with a frequency of 12 breaths per minute. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ a. co ve r th e wound with moistened, sterile saline dressings. b. notify the surgeon immediately. c. replace the protruding loops of bowel using sterile gloves. d. make the client rest on bed in supine position with flexed legs. 55. The nurse notes some alterations on the electrocardiogram (ECG) monitor (see figure). Which of the following serum potassium readings would the nurse associate to this finding? a. 3.1 mEq/L b. 4.2 mEq/L c. 4.5 mEq/L d. 6.4 mEq/L ANS: A 56. The nurse has instructed a client who is about to begin external radiation therapy “I need to keep the sun off the radiation site.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? a. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: B b. “I can use over-the-counter cortisone cream on the radiation site if it gets red.” c. “I need to be careful not to wash off the marks that the radiologist made on my skin.” d. “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.” 57. A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and the “freezing” experienced to walk. The nurse tells the client to: a. Sit in low chairs or sofas b. Rock back and forth to start movement c. Keep arms at both sides while walking d. Perform tasks with only the hand that has the tremor ANS:B 58. A ventilator’s low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client’s room and quickly assesses the client. The client appears to be having respiratory difficulty. What action would the nurse takes first: a. Call a code b. Suction the client NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 62. A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately: a. Pushes the cord gently back into the vagina b. Prepares the client for cesarean delivery c. Places the client in the knee-chest position d. Prepares to administer a tocolytic medication ANS:C 63. A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for: a. Bleeding b. A high fever c. Failure to thrive d. Signs of congestive heart failure (CHF) ANS:D 64. A nurse has been assigned to care for an infant with tetralogy of Fallot. The NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ infant suddenly exhibits rapid, deep respirations; and accentuated cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately: a. Calls a code b. Holds the infant in an upright position c. Flexes the knees against the trunk of the infant d. Administers oxygen by nasal cannula ANS:C 65. A nurse provides dietary instructions to the mother of a child with celiac disease. Which of the following foods does the nurse tell the mother to include in the child’s breakfast? a. Rice Krispies b. Wheat cereal c. Rye crackers d. Oatmeal biscuits ANS:A 66. A client with Meniere's disease is incapacitated by vertigo and is lying in bed NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? a. Encourage fluids to 3000 ml per day. b. Change the client's position every two hours. c. Keep the head of the bed elevated 30 degrees. d. Turn off the television and darken the room ANS:D 67. Several hours after surgical repair of an abdominal aortic aneurysm (AAA), the client develops left flank pain. The nurse determines the client's urinary output is 20 ml/hr for the past 2 hours. The nurse should conclude that these findings support which complication? a. Infection. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ d. discontinue use of all drugs metabolized in the liver. ANS:A 72. A nurse interviews a pregnant client regarding health maintenance behaviors. Which statement made by the client best demonstrates the need for further teaching? a. “I’ve been taking extra doses of vitamin A, because it will protect my skin from developing stretch marks.” b. “If I get a headache or my back hurts, I usually take two acetaminophen (Tylenol) tablets and rest for a while.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ c. “I have had diabetes for many years. Since my pregnancy advanced, I’ve noticed that I need a little more insulin every day.” d. “I should avoid taking my prenatal vitamins and minerals with milk or food.” ANS: A 73. A nurse is teaching a class on drugs that affect pediatric clients. During the discussion of age-related effects of medications in children, which statement made by a member of the class demonstrates a need for further teaching? a. “Glucocorticoids augment growth.” b. “Tetracyclines discolor the teeth.” c. “Sulfonamides cause kernicterus.” d. “Aspirin may cause Reye’s syndrome.” ANS:A 74. The nurse is developing a nursing care plan on a patient recently admitted with end stage renal failure (ESRF) and metabolic acidosis. The nurse plans the patient care based on the understanding that the compensatory mechanism for the correction of metabolic acidosis is in effect when the nurse observes: NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ a. increased urinary output. b. increase carbon dioxide (CO2) concentration. c. Kussmaul’s respirations. d. decreased bicarbonate (HCO3) concentration. ANS:C 75. A nurse working on an intensive care unit is caring for a client with increased intracranial pressure (ICP). The patient is to receive an opiate. The nurse questions the order, because a. clients with ICP are more prone to dysphoria, which can be produced when opiates are first initiated. b. the sedation that opiates produce can last longer in clients with ICP. c. opiates can be given to clients with ICP, although higher doses are required. d. opiates suppress respirations and therefore increase the CO2 content of the blood, which further increases the intracranial pressure. ANS:D 76. The nurse understands that the most effective way to preserve myocardial NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ketoacidosis (DKA). The orders include administration of an intravenous (IV) infusion of insulin and IV normal saline solution with potassium chloride added. Prior to hanging an IV containing potassium, the nurse will confirm that there is a: a. Normal blood pH and bicarbonate concentration. b. Urine output of at least 30 mL/hr. c. Filter on the IV line. d. Regular pulse of at least 60 beats/min. ANS:B 80. The postanesthesia care unit (PACU) nurse determines that the client’s Aldrete score is 9. The nurse on the postoperative unit understands the meaning of the Aldrete score as: a. client is at an increased risk for postoperative respiratory complications. b. client’s condition warrants close monitoring. c. client is experiencing severe pain. d. client will soon be transferred to the postoperative unit. ANS:D 81. The nurse is reviewing the presurgical client’s lab reports and notes an elevated NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ aspartate aminotransferase (AST) and bilirubin. The nurse is most concerned that this client is at risk for: a. excessive bleeding during or after surgery. b. an increased serum albumin level. c. postsurgical wound delayed healing and infection. d. an increased blood urea nitrogen (BUN) level. ANS:A 82. During the admission process, the nurse receives orders for the client to have arterial blood gases (ABGs) drawn. Which finding from the client’s history would concern the nurse? a. Taking ginkgo biloba for the last 6 months b. Having a decreased hematocrit (Hct) level during the last physical exam NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ c. Being diabetic for 1 year d. Having an increased white blood cell (WBC) count ANS: A 83. While assessing a client with type 2 diabetes mellitus, the nurse observes a lack of hair growthon the client's legs. What additional assessment provides further data to support this finding? a. Palpate for the presence of femoral pulses bilaterally. b. Assess for the presence of a positive Homan's sign. c. Observe the appearance of the skin on the client's legs and feet. d. Watch the client's posture and balance during ambulation. ANS:C 84. The healthcare provider performs a paracentesis on a client with ascitis and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Pedal pulses. b. Breath sounds. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 88. A client is complaining of pain in the left upper extremity where she has an intravenous (IV) catheter for the administration of antibiotics. The nurse assessing the IV insertion site finds the vein hard, the skin red, warm and tender, and a blood return in the IV line. The most effective intervention after removing the IV catheter is to: a. notify the nurse supervisor. b. elevate the arm above the level of the heart. c. clean the site and apply cool compresses. d. apply a warm moist pack. ANS:D 89. The nurse caring for a client with hypertension determines that there is no need for further instruction related to a low-sodium diet when the client states: a. “I can freely consume dried fruits.” b. “I’m looking forward to a glass of tomato juice.” c. “I’m going to eat my avocado and lettuce salad with olive oil.” d. “I’m going to season the turkey meatballs with extra catsup.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:C 90. A nurse has taught a client how to ambulate with a cane. The nurse determines that the client needs additional instruction on observing that: a. The client holds the cane at the level of the greater trochanter. b. The client holds the cane on the unaffected side. c. The client moves the cane and the unaffected side together. d. The client’s elbow has a flexion of around 28 degrees. ANS:C 91. A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches: a. 1-2 inches to the front and side of the toes. b. 6-8 inches to the front and side of the toes. c. 12-15 inches to the front and side of the toes. d. 20-22 inches to the front and side of the toes. ANS:B 92. A nurse is repositioning a client who has returned to the nursing unit after NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ internal fixation of a fractured right hip. The nurse should use a: NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ c. d. ANS:C 96. A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in the plan of care? a. Offering the client a sleeping pill at night b. Providing the client with a snack at bedtime c. Asking the client what she does to prepare for sleep d. Leaving the television in the client’s room on at a very low volume ANS:C 97. A client who is comatose, and receiving oxygen has cracked lips, dry mucus NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention by the nurse is to: a. Swab the mouth every half-hour with lemon-glycerin swabs. b. Swab lips and mucus membranes with mineral oil. c. Swab the oral cavity with a water-soaked sponge as needed. d. Swab the oral cavity with hydrogen peroxide, followed with water. ANS:C 98. The nurse is caring for a patient who refuses “AM care.” When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS: A a. Defer the bath until evening and pass on the information to the next shift. b. Tell the patient that she must bathe because that is the “normal” routine. c. Explain to the patient the importance of maintaining morning hygiene practices. d. Cancel hygiene for the day and attempt again in the morning. 99. The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because a. Plantar warts can develop from foot fungi. b. Poor foot care leads to neuropathy. c. A strong dorsalis pedis pulse indicates poor blood flow. d. Foot ulcers are the most common precursor to amputation. ANS:D 100. The nurse is discussing with a new mother the sleep requirements of a neonate. Which of these comments would indicate that the patient has an understanding of the neonate’s sleeping pattern? a. “I can’t wait to get the baby home to play with the brothers and sisters.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 104. Which nursing intervention should receive high priority in an elderly client being placed on the operating room table? a. Continued observation of the client’s cardiac monitor. b. Ensure that the correct operative site is exposed. c. Provide extra padding for joints and bony prominences. d. Understand which anesthetic agents are are going to be used. ANS:C 105. A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion ANS:C 106. The school nurse is teaching a nutrition class in the local high school. One student states that he has heard that certain foods can increase the incidence of cancer. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ The nurse responds, “Research has shown that certain foods indeed appear to increase the risk of cancer.” Which of the following menu selections would be the best choice for potentially reducing the risks of cancer? a. Smoked salmon and green beans b. Pork chops and fried green tomatoes c. Baked apricot chicken and steamed broccoli d. Liver, onions, and steamed peas ANS:C 107. Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is being placed on both primary and secondary prevention. What would be an example of primary prevention? a. Yearly Pap tests b. Testicular self-examination c. Teaching patients to wear sunscreen d. Screening mammograms ANS:C 108. The nurse teaching a young women’s community service group about breast NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ self-examination (BSE) will include that a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. annual mammograms should be scheduled in addition to BSE. d. performing BSE after the menstrual period is more comfortable. ANS:D 109. The nurse preparing for the annual physical exam of a 50-year-old man will plan to teach the patient about: a. endoscopy. b. colonoscopy. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ a. tend to be immature. b. do not need to use reasoned decision making. c. lack cognitive skills to use reasoned decision making. d. are dealing with issues that are stressful and emotionally laden. ANS:D 114. A 53-year-old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS). ANS:C NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 115. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? a. Administer sargramostim, granulocyte macrophage colony-stimulating factor (Leukine). b. Infuse packed red blood cells (PRBC) and platelet transfusions as ordered. c. Give indicated parental prophylactic antibiotics. d. Maintain a protective isolation environment. ANS:D 116. The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother? a. The child can be around other children but should wear a mask at all times. b. The child will no longer be contagious, no need to take any further precautions. c. Make sure there are no children under the age of 6 months around the infected child. d. Do not expose other children. RSV is very contagious even without direct oral NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ contact. ANS:D 117. The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client’s record? a. Ramipril (Altace) 2.5 mg was administered at 9 am. Physician called and incident report filed. b. Ramipril (Altace) 2.5 mg was administered at 9 am. Blood Pressure 128/82 mmHg. Physician called and new orders received. c. Twice the amount of the prescribed ramipril (Altace) was administered at 9 am. Patient is asymptomatic with stable vital signs. Physician called and new orders received. d. After the administration of an incorrect dose of ramipril (Altace) the client blood pressure was 128/82 mm Hg. Physician informed NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ c. Gloves, gown, and face shield. d. Gown, mask, and face shield ANS:C 122. After administration of preoperative medications, the nurse takes the precaution of: a. confirming that the client has voided. b. monitoring vital signs every 15 minutes. c. placing the client in bed with the rails up. d. transporting the client immediately to the OR. ANS:C 123. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to: a. Use alcohol-based gel on hands. b. Wash hands with soap and water. c. Remove eye protection and dispose of in garbage. d. Remove gloves and dispose of in garbage. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:D 124. A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. b. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. c. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. d. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:B 125. The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to a. Carry out the role and responsibilities of the nurse quickly and efficiently. b. Cluster all patients with the same symptoms to a specific part of the department. c. Determine the biologic agent and manage all patients using Standard Precautions. d. Prepare for post-traumatic stress associated with this bioterrorist attack. ANS:C 126. The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? a. “The number for poison control is 800-222-1222.” b. “Never induce vomiting if my grandchild drinks bleach.” c. “I should call 911 if my grandchild loses consciousness.” d. “If my grandchild eats a plant, I should provide syrup of ipecac.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ b. Regression c. Projection d. Denial ANS: D 131. A patient reports fears of having cervical cancer and says to the nurse, “I’ve had Pap smears by six different doctors. The results are normal, but I’m sure that’s because of errors in the laboratory.” Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Prominent health anxiety (hypochondriasis) c. Predominant (pain) disorder d. Dissociative fugue ANS:B 132. A patient with borderline personality disorder and a history of self-mutilation has now begun dialectical behavior therapy on an outpatient basis. Counseling focuses on self-harm behavior management. Today the patient telephones to say, “I’m feeling empty and want to cut myself.” The nurse should: a. arrange for emergency inpatient hospitalization. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to identify the trigger situation and choose a coping strategy. d. advise the patient to take an antianxiety medication to decrease the anxiety level. ANS:C 133. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential. ANS:B NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 134. A newly admitted patient with schizophrenia says, “The voices are bothering me. They yell and tell me I’m bad. I have got to get away from them.” Select the nurse’s most helpful reply. a. “Do you hear the voices often?” b. “Do you have a plan for getting away from the voices?” c. “I’ll stay with you. Focus on what we are talking about, not the voices.” d. “Forget the voices, and ask some other patients to play cards with you.” ANS:C 135. A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ a. “Will I ever be able to go back to my family and job?” b. “I don’t ever want to feel so out of control ever again.” c. “Will you please ask the doctor if I can have a pill for my nerves?” d. “I will let you know if I start feeling the need to hurt myself again.” ANS:D 140. The nurse has developed a plan in which nursing interventions are used to reinforce the patient’s healthy behaviors. Which statement by the nurse will positively reinforce the patient’s efforts regarding the plan? a. “How can a stress reduction plan help you at home?” b. “It sounds like you have the incentive to make healthy choices.” c. “When you tried to follow the plan, how well did it work for you?” d. “It sounds as though making healthy choices is very important to you.” NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:B Multiple Response Identify one or more choices that best complete the statement or answer the question. 141. The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are parts of the nurse’s new role? Select all that apply. a. Evaluating and updating the plan of care as needed b. Prescribing treatments specific to the client’s needs c. Assessing the client’s needs for home supplies and equipment d. Coordinating consultations and referrals to facilitate discharge e. Establishing a safe and cost-effective plan of care with the client ANS:A, C, D, E 142. A nurse monitors a client with a tumor of the esophagus for signs of superior vena cava (SVC) syndrome. Which of the following are signs of this complication? Select all that apply: a. Tightness of the shirt collar (Stokes’ sign) b. Edema around the eyes NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ c. Edema in the hands d. Difficulty breathing e. Mental status changes f. Bruises on the chest (Turner’s sign) ANS:A, B, C, D, E 143. The nurse prepares a list of home care instructions for a client following total hip replacement. Which instructions should the nurse include on the list? Select all that apply. a. If experience pain while sitting, elevate the legs as much as possible. b. Use assistive devices for putting on shoes and socks. c. Sleep in supine position with a pillow between the legs. d. Use an elevated toilet seat. e. Cleanse the hip incision with a mild soap and water daily. f. When driving, move the car seat as near as possible to the steering wheel. ANS:B, C, D, E 144. The nurse provides home care instructions for a client with peripheral neuropathy of the lower extremities. The nurse includes which instructions in the teaching plan? Select all that apply. NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 147. A nurse provides information to a client who will be receiving relaxation therapy. The nurse tells the client that which effects occur from this type of therapy? Select all that apply. a. Increased heart rate b. Reduce sympathetic activity c. Lowered blood pressure d. Increased respiratory rate e. Decreased muscle tone f. Increased neural impulses to brain ANS:B, C, E 148. The nurse provides dietary instructions to a client who has a folic acid deficiency. Which foods should the nurse instruct the client to consume? Select all that apply a. Liver b. Eggs c. Carrots d. Oranges e. Broccoli f. Brussels sprouts NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ ANS:A, B, E, F 149. The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)? a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine d. Trimethoprim-sulfamethoxazole e. Varicella zoster immune globulin ANS:A, B, C NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ NURSING NCLEX3165 DMC exit 814 (150 Q & AS) BEST EXAM SOLUTION SATISFACTION UARANTEED SUCCESS LATEST UPDATE 2022/2023 GRADED A+ 150. Which of the following concepts are important to utilize when evaluating orders for restraints? (Select all that apply.) a. Behaviors that necessitate the use of restraint are part of the nursing plan of care. b. A physician’s order is required for restraint and includes a face-to-face evaluation. c. The physician’s preference for the format of the order can override agency policy. d. Orders are time limited. Restraints are not ordered prn (as needed). e. It should be specified that restraints are to be removed periodically. f. Restraint orders are time dated and signed by the physician.