200 question nclex exam

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Question 1   See full question A client is scheduled to have a graded exercise test. The nurse explains to the client that the test will determine how: You Selected: well the body reacts to contr... olled exercise stress. Correct response: well the body reacts to controlled exercise stress.  Explanation: Graded exercise testing is a diagnostic and prognostic tool used to determine the physiologic responses to controlled exercise stress. Information gained from a graded exercise test can achieve diagnostic, functional, and therapeutic objectives for the client. Graded exercise tests involve the use of a treadmill, stationary bicycle, or arm ergometry. The information obtained from this test is not used to set the incline on the treadmill, and measuring the distance walked and the duration of the walk are not the purpose of a graded exercise test.  Remediation: Electrocardiography, exercise Question 2   See full question A nurse should include which discharge instruction for clients receiving tricyclic antidepressants? You Selected: Restrict fluid and sodium intake while using this medication. Correct response: Don't consume alcohol while using this medication.  Explanation: Drinking alcohol can potentiate the sedating action of tricyclic antidepressants. Dry mouth and blurred vision are normal adverse effects of tricyclic antidepressants. Fluid and sodium intake must be monitored during lithium treatment, not during treatment with tricyclic antidepressants. Safe use of tricyclic antidepressants during pregnancy and breast-feeding hasn't been established.  Remediation: Amitriptyline hydrochloride Clomipramine hydrochloride Question 3  See full question The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a client with cholecystitis who has nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. Your Response: 0.7 Correct response: 1.4  Explanation: The following formula is used to calculate the correct dosage: 35 mg/X = 25 mg/1 mL X = (35/25) mL X = 1.4 mL. Question 4   See full question Levothyroxine 0.2 mg orally has been prescribed for a client diagnosed with hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should the nurse prepare to give the client? You Selected: two tablets Correct response: four tablets  Explanation: 0.2 mg/x tablet = 0.05 mg/1 tablet. x = 4 tablets.  Remediation: Levothyroxine sodium Question 5   See full question What is the nurse’s priority intervention for a toddler who has just had a hip-spica cast applied? You Selected: Assess sensation, circulation, and motion of the child’s feet and toes Correct response: Assess sensation, circulation, and motion of the child’s feet and toes  Explanation: Assessing sensation, circulation, and motion is necessary in all children with a cast. Fluids should be encouraged, and careful diapering and padding will keep the child’s cast dry. Discharge instructions are not a priority, but should be shared at a later time. Children experiencing pain should receive medication as needed.  Remediation: Cast assessment and management, pediatric Casting, pediatric Question 6   See full question A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? You Selected: 27 gtts/min Correct response: 27 gtts/min  Explanation: The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min  Remediation: IV infusion, dose and flow rate calculations Question 7   See full question Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which action would be most appropriate? You Selected: Give the infant small, frequent feedings. Correct response: Give the infant small, frequent feedings.  Explanation: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Giving large, less frequently feedings allows for rest, but typically results in more vomiting.  Remediation: Ventriculoperitoneal shunt placement Hydrocephalus, pediartic Question 8   See full question A 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first? You Selected: Make an appointment with the adolescent's health care provider (HCP). Correct response: Make an appointment with the adolescent's health care provider (HCP).  Explanation: A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider (HCP) to determine the cause. Unexplained headaches and vomiting along with difficulty walking (e.g., ataxia) may suggest a brain tumor. Evaluation by an eye HCP would be appropriate once a complete medical evaluation has been accomplished. Psychological counseling may be indicated for this adolescent, but only after medical evaluation to determine that she is physically healthy. Meeting with the child’s teachers would be appropriate after medical evaluation.  Remediation: Physical assessment, pediatric Question 9   See full question A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: You Selected: tea and gelatin dessert. Correct response: tea and gelatin dessert.  Explanation: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.  Remediation: Vomiting Question 10   See full question Clozapine therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, "Why do I have to have a blood test every week?" Which response by the nurse would be most appropriate? You Selected: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood." Correct response: "Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood."  Explanation: The client needs specific information about the effects of the drug, specifically that the drug can cause agranulocytosis. The statement about weekly blood tests to determine safe dosage and monitoring for effects on the blood gives the client specific information to ensure follow-up with the required protocol for clozapine therapy. Lack of accurate knowledge can lead to noncompliance with necessary follow-up procedures and noncompliance with medication. The supply of medication is not dependent on blood testing. Telling the client that the health care provider (HCP) wants to know the progress does not provide specific information for this client. The blood tests are not required by the drug company.  Remediation: Clozapine Question 11   See full question A nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation? You Selected: "Rehabilitation will help me function as well as I physically can." Correct response: "Rehabilitation will help me function as well as I physically can."  Explanation: The client demonstrates understanding of cardiac rehabilitation when he states that it helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn't cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education.  Remediation: Myocardial infarction Myocardial Blood Flow Question 12   See full question While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? You Selected: Risk for impaired skin integrity related to immobility Correct response: Risk for impaired skin integrity related to immobility  Explanation: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about himself and his disease.  Remediation: Pressure ulcer prevention Question 13   See full question A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury? You Selected: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Correct response: Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed.  Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others.  Remediation: Confused patient, care of Question 14   See full question A nurse is caring for a client diagnosed with cardiomyopathy. The student nurse assigned to collaborate with the nurse begins data collection for the admission assessment. The student nurse violates information security when she: You Selected: writes the client's phone number on her clinical paperwork. Correct response: writes the client's phone number on her clinical paperwork.  Explanation: Documenting identifying information taken outside the institution is violates information security. The student nurse has no need for the client's phone number on her clinical paperwork in order to provide care. Completing admission paperwork and data collection sheets is within the scope of practice for the student nurse and doesn't violate information security.  Remediation: Documentation Question 15   See full question When obtaining a client's history, a nurse develops a genogram. What is the purpose of developing a genogram? You Selected: To identify genetic and familial health problems Correct response: To identify genetic and familial health problems  Explanation: A genogram organizes a family's history into a diagram or flow chart. A nurse uses a genogram to identify genetic and familial health problems. A genogram doesn't identify previously undetected diseases and disorders, the client's reason for seeking care, or chronic health problems. Question 16   See full question A nurse is caring for a toddler who was diagnosed with an inoperable brain tumor. The parents are having difficulty deciding on a course of action for their child. Why is it important to have the nurse involved in an ethical discussion about a planned course of treatment? You Selected: The nurse can act as a liaison between the child, the child's parents, and the health care team. Correct response: The nurse can act as a liaison between the child, the child's parents, and the health care team.  Explanation: It is important to involve the nurse because she can act as a liaison between all parties. The nurse has the most direct contact with the child and his parents, and she can listen to and communicate their wishes for treatment. She can also aid in interpreting information about the child's condition and course of treatment, helping the parents to make an informed decision. The nurse isn't viewed as the authority on ethical issues at the hospital. In fact, hospitals commonly employ ethicists to help with ethical dilemmas. Time shouldn't be a factor when it comes to helping parents make decisions about their child's care. Question 17   See full question Because antianxiety agents such as chlordiazepoxide can potentiate the effects of other drugs, the nurse should incorporate which instruction in her teaching plan? You Selected: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants. Correct response: Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants.  Explanation: Potentiating effect refers to a drug's ability to increase the potency of another drug if the two drugs are taken together. Therefore, the client should be instructed to avoid alcohol while taking chlordiazepoxide because alcohol potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Chlordiazepoxide comes in capsule form and can usually be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not antianxiety agents.  Remediation: Chlordiazepoxide hydrochloride [Show More]

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