Praktická zkouška NCLEX Select All That Apply 10
An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action?
Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.
When caring for a 3-year-old child, the nurse should provide which toy for this child?
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.
When caring for a 3-year-old child, the nurse should provide which toy for this child?
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may contain items that the child could swallow.
A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty:
The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect.
A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
Answers A, B, and C are incorrect because they contain lower amounts of potassium. (Note that the banana contains 450mg K+, the orange contains 235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.)
The nurse is caring for a client following removal of the thyroid. Immediately post-op, the nurse should:
Following a thyroidectomy, the client should be placed in semi-Fowler’s position to decrease swelling that would place pressure on the airway. Answers B, C, and D are incorrect because they would increase the chances of postoperative complications that include bleeding, swelling, and airway obstruction.
A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer?
Luncheon meats contain preservatives such as nitrites that have been linked to gastric cancer. Answers A, B, and C have not been found to increase the risk of gastric cancer; therefore, they are incorrect.
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client’s record, the nurse could expect to find:
A history of cruelty to people and animals, truancy, setting fires, and lack of guilt or remorse are associated with a diagnosis of conduct disorder in children, which becomes a diagnosis of antisocial personality disorder in adults. Answer A is incorrect because the client with antisocial personality disorder does not hold consistent employment. Answer B is incorrect because the IQ is usually higher than average. Answer D is incorrect because of a lack of guilt or remorse for wrong-doing.
The licensed vocational nurse may not assume the primary care for a client:
The licensed vocational nurse may not assume primary care of the client with a central venous access device. The licensed vocational nurse may care for the client in labor, the client post-operative client, and the client with bipolar disorder; therefore, answers A, B, and D are incorrect.
The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to:
Sulfamylon produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Answers B, C, and D do not pertain to dressing changes for the client with burns, so they are incorrect.
The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler?
According to the Denver Developmental Screening Test, the child can pull a toy behind her by age 2 years. Answers B, C, and D are not accomplished until ages 4–5 years; therefore, they are incorrect.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Answer B is incorrect because the wires would prevent insertion of an oral airway. Answer C is incorrect because it would be of no use in releasing the wires. Answer D is incorrect because it would be used only as a last resort in case of airway obstruction.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
Changes in breath sounds are the best indication of the need for suctioning in the client with ineffective airway clearance. Answers A, B, and D are incorrect because they can be altered by other conditions.
A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
An adverse reaction to Myambutol is change in visual acuity or color vision. Answer A is incorrect because it does not relate to the medication. Answer C is incorrect because it is an adverse reaction to Streptomycin. Answer C is incorrect because it is a side effect of Rifampin.
The primary cause of anemia in a client with chronic renal failure is:
Insufficient erythropoietin production is the primary cause of anemia in the client with chronic renal failure. Answers A, B, and C do not relate to the anemia seen in the client with chronic renal failure; therefore, they are incorrect.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
The contrast media used during an intravenous pyelogram contains iodine, which can result in an anaphylactic reaction. Answers A, C, and D do not relate specifically to the test; therefore, they are incorrect.
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NCLEX Select All That Apply #11