NR 224 NCLEX Questions Week 2

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NR 224 NCLEX Questions Week 2 1. Which actions are important when the nurse uses a stretcher? Select all that apply. (Nugent & Vitale, 2012, p. 195) a. Lowering the bed below the level of the stret... cher when transferring a patient from the stretcher to a bed. b. Guiding the stretcher around a turn leading with the end with the patients head c. Ensuring the patient’s head is at the end with the swivel wheels d. Pulling the stretcher on the elevator with the patient’s feet first. e. Pushing the stretcher from the end with the patient’s head. 2. The client’s temperature at 0800 using an oral electronic thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next? (Berman & Snyder, 2012, p. 571) a. Wait 15 minutes and retake it. b. Check what the client’ temperature was the last time it was taken. c. Retake it suing a different thermometer. d. Chart the temperature; it is normal. 3. For a client with a previous blood pressure of 138/74 and pulse of 64, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? (Berman & Snyder, 2012, p. 571) a. 10-20 seconds b. 30-45 seconds c. 1-1.5 minutes d. 3-3.5 minutes 4. It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel (UAP)? (Berman & Snyder, 2012, p. 571) a. A client being prepared for elective facial surgery with a history of stable hypertension. b. A client receiving a blood transfusion with a history of transfusion reactions c. A client recently started on a new antiarrhythmic agent. d. A client who is admitted frequently with asthma attacks. 5. An 85 year old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are appropriate for taking the temperature? Select all that apply. (Berman & Snyder, 2012, p. 571) a. Oral b. Rectal c. Axillary d. Tympanic e. Temporal artery 6. To increase stability during client transfer, the nurse increases the base of support by performing which action? (Berman & Snyder, 2012, p. 1179) a. Leaning slightly backward b. Spacing the feet farther apart c. Tensing the abdominal muscles d. Bending the knees 7. Five minutes after the client’s first postoperative exercise the client’s vital signs have not yet returned to baseline, which is an appropriate nursing diagnosis? (Berman & Snyder, 2012, p. 1180) a. Activity Intolerance b. Risk for Activity Intolerance c. Impaired Physical Mobility d. Risk for Disuse Syndrome 8. Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? (Berman & Snyder, 2012, p. 1180) a. “Going up, the strong leg goes first, then the weaker leg with both crutches.” b. “Going down, the weaker leg goes first with both crutches, then the strong leg.” c. “The weaker leg always goes first with both crutches.” d. “A cane or single crutch may be used instead of both crutches if held on the weaker sid [Show More]

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