Nclex Masters- Nclex 150 Questions Answers And Clinical Reasoning And Strategy

NCLEX150QUESTIONSANSWERSANDCLINICALREASONING EXAMPREP#4 1.Ayoungadultwhowasinamotorcycleaccidenti sbroughttotheemergencyroomwithaclosedheadinjurywithsuspe ctedsubduralhematoma.Althoughtheclientcomplainsofasevere headache,heisalertandanswersquestionsappropriately.Thenursewoul dquestionwhichofthefollowingorders? 1.Promethazine(Phenergan)25mgIM3h.2.Morphinesulfate10mgIMq3-4h. 3.Docusatesodium(Colace)50mgPObid. 4.Ranitidine(Zantac)50mgIVPBq12h.Strategy:Allanswersareimplementations.Determin etheoutcomeofeachanswerchoice.Isitdesired? (1)H1receptorblocker,usedasanantiemetic(2)correct-narcoticanalgesic,causesCNSandresp iratorydepression,contraindicatedinheadinjurybecauseitmaskssignsofincreasedintracra nialpressure(3)stoolsoftener,usedforanimmobilizedpatient (4)H2histamineantagonist,reducesacidproductio ninstomach,preventsstressulcers2.Thenursehasjustreturnedtothedeskandhas fourphonemessagestoreturn.Whichofthefollowingmessagesshouldthe nursereturnFIRST?1.Awomaninherfirsttrimesterofpregnancycomp lainingofheartburn.2.Amancomplainingofheartburnthatradiatesto hisjaw.3.Awomancomplainingofhotflashesanddifficult ysleeping.4.Aboycomplainingofkneepainafterplayingbas ketball.Strategy:Determinetheleaststableclient. (1)causedbyrefluxofgastriccontentsintoesoph agus,treatmentissmallfrequentmeals,dontconsumefluidswithfood,dontweartightclothing (2)correct-indicateschestpain,needstoseekmed icalattentionimmediately(3)causedbymenopause,treatwithhormonereplace menttherapy(HRT)(4)shouldtreatwithrestandice 3.Apatientisadmittedtothesurgicalunitwith adiagnosisofruleoutintestinalobstruction.Thenurseispreparingtoi nsertaSalemsumpNGtubeasordered.Inwhichofthefollowingposition swoulditbeBESTforthenursetoplacethispatientduringtheprocedure? 1.Headofbedelevated30-45.2.Headofbedelevated60-90. 3.Side-lyingwithheadelevated15. 4.Lyingflatwithheadturnedtotheleftside. Strategy:Rememberthepositioningstrategy.(1)notthebestposition (2)correct-facilitatesswallowingandmovementof tubethroughGItract(3)notthebestposition (4)notthebestposition 4.Thenurseismonitoringthefluidstatusofa63 -year-oldwomanreceivingIVfluidsfollowingsurgery.Whichofthefollowing symptomswouldsuggesttothenursethatthepatienthasfluidvolumeover load?1.Temperature101F(38.3C),BP96/60,pulse96a ndthready.2.Coolskin,respiratorycrackles,pulse86andbo unding.3.Complaintsofaheadache,abdominalpain,andle thargy.4.Urinaryoutput700cc/24h,CVPof5,andnystag mus. Strategy:Determinehoweachanswerchoicerelates tofluidvolumeoverload. (1)indicatesdehydration(2)correct-willseeboundingpulse,elevatedBP,d istendedneckveins,edema,headache,polyuria,diarrhea,liverenlargement (3)symptomscouldbefromcausesotherthanvolume overload(4)slightlyreducedoutput,CVPwouldbeelevated, normalCVP4-10mm/H2O,involuntaryeyemovementsnotseen5.Awomanhasbeenrecentlydiagnosedwithsystemi clupusandshareswiththenurse,Iamthinkingaboutgettingpregna nt,butIdontknowhowIwillbeabletotolerateapregnancysinceI havelupus.WhichofthefollowingresponsesbythenurseisBEST? 1.Mostwomenfindthattheyfeelbetterwhenthey arepregnant.2.Howlonghaveyoubeeninremission? 3.Womenwithlupusfrequentlyhaveslightlylonge rgestations.4.Itisbesttobecomepregnantwithinthefirst sixmonthsofdiagnosis.Strategy:Answersareamixofassessmentsandimpl ementations.Doesthissituationrequireassessment?Yes. (1)maternalmorbidityandmortalityareincreased withSLE(2)correct-shouldbeinremissionforatleast5m onthspriortoconceiving(3)gestationnotaffectedbySLE(4)recommendedthatawomanwaittwoyearsfollowi ngdiagnosisbeforeconceiving6.Themultidisciplinaryteamdecidestoimplement behaviormodificationwithaclient.Whichofthefollowingnursingactio nsisofprimaryimportanceduringthistime? 1.Confirmthatallstaffmembersunderstandandco mplywiththetreatmentplan.2.Establishmutuallyagreedupon,realisticgoals. 3.Ensurethatthepotentreinforcers(rewards)are importanttotheclient.4.Establishafixedintervalscheduleforreinforc ement. Strategy:Allanswersareimplementations.Determinetheoutcomeofeachanswerchoice.Isitdesired? (1)correct-toimplementabehaviormodificationpl ansuccessfully,allstaffmembersneedtobeincludedinprogramdevelopment,andtim emustbeallowedfordiscussionofconcernsfromeachnursingstaffmemb er;consistencyandfollow-throughisimportanttopreventordiminishthelev elofmanipulationbythestafforclientduringimplementationofthisprogram (2)notofprimaryimportanceindesigninganeffec tivebehaviormodificationprogram(3)notofprimaryimportanceindesigninganeffec tivebehaviormodificationprogram (4)notofprimaryimportanceindesigninganeffec tivebehaviormodificationprogram 7.Aclientreceivedsixunitsofregularinsulint hreehoursago.ThenursewouldbeMOSTconcernedifwhichofthefollowingw asobserved?1.Kussmaulrespirationsanddiaphoresis. 2.Anorexiaandlethargy. 3.Diaphoresisandtrembling.4.Headacheandpolyuria. Strategy:MOSTconcernedindicatesacomplication .(1)Kussmaulrespirationsaresignsofhyperglycemi a(2)notindicativeofhypoglycemia (3)correct-regularinsulinpeaksintwotofourho urs;indicateshypoglycemia;giveskimmilk(4)notindicativeofhypoglycemia 8.Thenursingassistantreportstothenursethat aclientwhoisone-daypostoperativeafteranangioplastyisrefusingtoe atandstates,Ijustdontfeelgood.Whichofthefollowingactions,iftake nbythenurse,isBEST?1.Thenursetalkswiththeclientabouthowheis feeling.2.Thenurseinstructsthenursingassistanttosit withtheclientwhileheeats.3.Thenursecontactsthephysiciantoobtainanor derforanantacid.4.Thenurseevaluatesthemostrecentvitalsigns recordedinthechart. Strategy:Answersareamixofassessmentsandimpl ementations.Doesthissituationrequireassessment?Yes.Istheassessmen tappropriate?Yes.(1)correct-assessmentrequired;monitorforclosur eofvessel,bleeding,hypotension,dysrhythmias(2)assesscauseofproblembeforeimplementing(3)assesscauseofproblembeforeimplementing (4)moreimportanttoassesswhatishappeningnow 9.Thenursepreparesa25-year-oldwomanforacesareansection.Thepatientsaysshehadmajorsurgeryseveralyearsag oandasksifshewillreceiveasimilarshotbeforesurgery.Thenurse sresponseshouldbebasedonanunderstandingthatthepreoperativemed icationgivenbeforeacesareansection 1.containsaloweroveralldosageofmedicationth anisgivenbeforegeneralsurgery. 2.containsreducedamountsofsedativesandhypnot icsthanaregivenbeforegeneralsurgery. 3.containsreducedamountsofnarcoticsthanareg ivenbeforegeneralsurgery.4.containsmedicationssimilarintypeanddosages tothosegivenbeforegeneralsurgery.Strategy:Thinkabouttheactionofthemedications .(1)decreaseddosageofnarcoticsareused(2)dosagesofsedativesandhypnoticswillbesimi lar(3)correct-decreasedsolessnarcoticcrossesthe placentalbarriercausingrespiratorydepressionintheinfant(4)dosagesofnarcoticsarereduced 10.Thenurseiscaringforan11-year-oldpatient beingtreatedforafracturedrightfemurwithbalancedsuspensiontrac tionwithaThomassplintandPearsonattachment.Thenursenotesthat thepatientsleftlegisexternallyrotated.Thenurseshould 1.placeatrochanterrollontheouteraspectoft hethigh.2.performresistiverangeofmotionoftheleftle g.3.adductandinternallyrotatetheleftleg.4.instructthepatienttomaintaintheleftlegin aneutralposition.Strategy:Answersareimplementations.Determineth eoutcomeofeachanswerchoice.Isitdesired? (1)correct-holdshipinneutralpositionandlegi nnormalalignment,entireweightoflegcannotbeheldbypropsplacedbelowknee (2)exercisewouldnotpreventfutureexternalrota tionoftheleg(3)adduct(addtomidlineofbody)doesnotchange externalrotation,internalrotationisnotbeneficial,normalalignmentisreq uired(4)legwillexternallyrotateunlessproppedinpr operalignment 11.Thenurseispreparingafive-year-oldchildfo rsurgery.Thenursenotesthatthechildsparentsaredivorcedandhavejoin tlegalcustody.Theinformedconsentforsurgeryhasbeensignedbythe mother.WhichofthefollowingactionsbythenurseisBEST? 1.Notifythephysician. 2.Informsurgery. 3.Contactthefathertoobtainconsent.4.Continuethechildspreoperativepreparation. Strategy:Allanswersareimplementations.Determinetheoutcomeofeachanswerchoice.Isitdesired? (1)noreasontonotifythephysician (2)noreasontocalltheOR (3)consentfromeitherdivorcedparentissufficie nt(4)correct-parentorlegalguardianrequiredtogi veinformedconsentpriortosurgicalprocedure 12.Thenurseiscaringforclientsontheneurolog yunit.WhatwouldbetheMOSTappropriateactionforthenursetotakeafter notingthataclientsuddenlydevelopedafixedanddilatedpupil? 1.Reassessinfiveminutes.2.Checktheclientsvisualacuity.3.Lowertheheadoftheclientsbed. 4.Contactthephysician. Strategy:Answersareamixofassessmentsandimpl ementations.Isthisasituationthatrequiresassessmentorvalidation?N o.Determinetheoutcomeoftheimplementations. (1)assessment,situationdoesnotrequirevalidati on(2)assessment,hassymptomsofincreasedICP (3)implementation,wouldincreasetheintracranial pressure(4)correct-implementation,fixedanddilatedpupil representsaneurologicalemergency 13.Amotherbringshertwo-year-oldboytotheped iatriciansoffice.Whichofthefollowingsymptomswouldsuggesttothenurs ethatthechildhasstrabismus? 1.Whenthechilddraws,heplaceshisheadcloset othetable.2.Thechildrubshiseyesfrequently.3.Thechildclosesoneeyetoseeaposteronthe wall.4.Thechildisunabletoseeobjectsintheperiph eryofhisvisualfield.Strategy:Thinkabouteachanswerchoice. (1)suggestiveofrefractiveerror,myopia(nearsig htedness),abletoseeobjectsatcloserange(2)suggestiveofrefractiveerror(3)correct-visualaxesarenotparallelsothebra inreceivestwoimages(4)suggestiveofcataractsorproblemwithperiphe ralvision14.Aclientisgivenmorphine6mgIVpushforpos toperativepain.Followingadministrationofthisdrug,thenurseob servesthefollowing:pulse68,respirations8,BP100/68,clientsleepin gquietly.WhichofthefollowingnursingactionsisMOSTappropriate? 1.Allowtheclienttosleepundisturbed. 2.Administeroxygenviafacemaskornasalprongs.3.Administernaloxone(Narcan).4.Placeepinephrine1:1,000atthebedside. Strategy:Allanswersareimplementations.Determinetheoutcomeofeachanswerchoice.Isitdesired? (1)shouldbegivenNarcanforlowrespiratoryrate (2)problemislowrespirations,thismaybeadmini steredaftermedication(3)correct-IVnaloxone(Narcan)shouldbegivento reverserespiratorydepression;respiratoryrate of8istoolowandnecessitatesanursingaction(4)unnecessary 15.Theschoolnurseisteachingagroupofprescho olmothersaboutpoisonpreventioninthehome.Whichofthefollowingstat ements,ifmadebyamothertothenurse,indicatesthatfurtherteachin gisnecessary?1.IshouldhaveabottleofIpecacforeachofmy children.2.Ishouldinducevomitingifmychildswallowsl ighterfluid.3.Givingmychildwaterormilkmayhelpdilutet hepoison.4.Properstorageisthekeytopoisonprevention inthehome. Strategy:Furtherteachingisnecessaryindicates anincorrectstatement.(1)Ipecacisavailablein30ccvials,advisepare ntstohaveavailablefulldosesforeachchild,dosesrangefrom10to30cc (2)correct-vomitingcontraindicatedwhenchilding estshydrocarbonsduetodangerofaspiration(3)smallamountsofwaterormilkmaydilutetoxin s(4)storeinlockedcabinets 16.Thenurseiscaringforamanicclientinthes