NCLEX Trainer Test 10

NCLEX Trainer Test 10 Related

Review NCLEX Trainer Test 10 related questions and content

An elderly alcoholic client has been receiving a long-acting benzodiazepine (Librium) for two days for symptom management and reduction. The client states: 'Get those bugs off of me and clean them out of here.'

The nurse knows the client is exhibiting symptoms of

  • A. a reaction to the sedative medication.
  • B. a worsening course of the withdrawal syndrome.
  • C. an exacerbation of the schizophrenia process.
  • D. the process of aging and the effects of delirium.
Correct Answer: B

Rationale: Strategy: Think about each answer choice. (1) client has been medicated with benzodiazepines and did not experience untoward reactions (2) correct-client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations (3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations (4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium, but rather dementia

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The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?

  • A. Prevent iron deficiency anemia.
  • B. Decrease touch to prevent overstimulation.
  • C. Provide feedings via gavage to decrease energy expenditure.
  • D. Replace vitamins depleted as a result of poor maternal diet.
Correct Answer: D

Rationale: frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?

  • A. Massage the client's legs to increase circulation.
  • B. Elevate the knee gatch to reduce stress on the suture line.
  • C. Apply thigh-high TED hose to promote venous return.
  • D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C

Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation

The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus?

  • A. A 19-year-old four days postpartum with an obstetrical history of placenta previa.
  • B. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago.
  • C. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily.
  • D. A 22-year-old leukemic client with a platelet count of 120,000/mm³ and a hemoglobin level of 9.0 g.
Correct Answer: B

Rationale: obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli

A client who has just indicated a wish to kill herself and asks the nurse not to tell anyone.

The nurse's BEST response should be to

  • A. encourage the client not to do anything without thinking it through very carefully.
  • B. explain to the client that anything she tells the nurse is kept strictly confidential.
  • C. report this to staff members in order to protect the client.
  • D. encourage the client to tell the nurse more about what she is feeling.
Correct Answer: C

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not answer client's immediate concern or give client accurate information about what the nurse will do (2) does not answer client's immediate concern or give client accurate information about what the nurse will do (3) correct-nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved (4) does not answer client's immediate concern or give client accurate information about what the nurse will do

The nurse is monitoring a 20-year-old woman in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if

  • A. the contractions occur at 3-minute intervals and last more than 60 seconds.
  • B. the contractions occur at 2.5-minute intervals and last more than 60 seconds.
  • C. the contractions occur at 2-minute intervals and last more than 90 seconds.
  • D. the contractions occur at 2-minute intervals and last more than 60 seconds.
Correct Answer: C

Rationale: contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds) allows for longer resting time between contractions

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