NCLEX Trainer Test 8

NCLEX Trainer Test 8 Related

Review NCLEX Trainer Test 8 related questions and content

A client with posttraumatic stress disorder (PTSD).

One of the goals the nurse and a client with posttraumatic stress disorder (PTSD) mutually agreed upon is that he will increase his participation in out-of-the apartment activities. Which of the following recommendations, if made by the nurse, will be MOST therapeutic to achieve this goal?

  • A. Take a day trip with a friend.
  • B. Take an eleven-minute bus ride alone.
  • C. Join a support group and participate in a victim assistance organization.
  • D. Take a ten-minute walk with his wife around the block.
Correct Answer: C

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (2) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (3) correct-support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath (4) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated

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A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:

  • A. Remove the unsightly markings with acetone or alcohol.
  • B. Cover the radiation site with loose gauze dressing.
  • C. Sprinkle baby powder over the radiated area.
  • D. Refrain from using soap or lotion on the marked area.
Correct Answer: D

Rationale: Refraining from using soap or lotion preserves radiation site markings, ensuring accurate treatment. Removing markings, covering, or using powder risks disrupting the treatment field.

The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:

  • A. Prepare the client for a return to surgery.
  • B. Apply traction to the urethral catheter.
  • C. Document the findings as normal.
  • D. Decrease the client's oral fluid intake.
Correct Answer: B

Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.

The nurse is caring for a client with a history of Addison’s disease.

  • A. Which laboratory finding is most concerning for a client with Addison’s disease?
  • B. Serum sodium of 128 mEq/L.
  • C. Serum cortisol of 10 µg/dL.
  • D. Blood glucose of 90 mg/dL.
  • E. Serum potassium of 4.0 mEq/L.
Correct Answer: A

Rationale: A serum sodium of 128 mEq/L indicates hyponatremia, a life-threatening complication in Addison’s disease due to aldosterone deficiency, risking shock. Low cortisol is expected, and normal glucose and potassium are unremarkable.

Which of these clients would the triage nurse request the provider examine immediately?

  • A. A 5 month-old infant who has audible wheezing and grunting
  • B. An adolescent who has soot over the face and shirt
  • C. A middle-aged man with second degree burns over the right hand
  • D. A toddler with singed ends of long hair that extends to the waist
Correct Answer: A

Rationale: A 5 month-old infant who has audible wheezing and grunting. The age and the findings suggest this client is at immediate risk for respiratory complications.

A client before administration of captopril (Capoten).

The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's

  • A. apical pulse for 60 seconds.
  • B. blood pressure.
  • C. urine output.
  • D. temperature.
Correct Answer: B

Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication

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