NCLEX Select All That Apply Practice Exam 5
The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:
The client is displaying paranoid behaviours, which necessitates a matter of fact approach that is nonjudgmental and accepting the client’s statements and show the nurses willingness to actively listen. The last three do not contribute to a therapeutic nurse client relationship.
Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:
Elevating the head of the bed to 30 degrees or less will decrease the chance of ulcer development from shearing forces. When placing the client in a side lying position, use the 30 degree lateral inclined position. Do not place the client on their trochanter. Avoid donuts which promote ischemia. Don’t massage bony prominences as this causes capillary break down and injury leading to pressure ulcers.
The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:
Medications must be evaluated in terms of their potential for increasing the intraocular pressure. Ophthalmic drops are often prescribed for glaucoma and clients should know how to administer them correctly. Diabetes is a risk factor and its mgmt is important in helping slow POAG. An increase in intraocular pressure could cause further damage to a patient with POAG. The questions states the client is already diagnosed, POAG is painless and not correlated to BP.
A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:
Rapid outflow doesn’t cause pain, warming helps with discomfort and the dialysate does not infiltrate the circulation.
The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:
Primary action of hemodialysis is to clear nitrogenous waste products.
The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:
Indications for dialysis include volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normally 10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along with decreased urinary creatinine clearance. The K level is hyperkalemic, the BUN is normal.
The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:
Paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. With a femur fracture the will be edema, a decrease in rate is not an indication of pressure, a decrease in pulse strength is. Anger can be due to immobility, and the pins do not usually cause pain, but this may be a sign of infection.
The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:
This will all help neutralize stomach acid. Drinking lots with meals and eating before bed will exacerbate the problem.
The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:
In cardiac catheterization contrast dye is injected into the coronary artery and provides info on patency. Informed consent must be signed prior to any invasive procedure. The physician is responsible for explaining the procedure, the nurse can reinforce. Patient would be NPO 6-18 hours prior. An ECG would be done, but measures electrical not blood flow. Peripheral pulses is important afterwards. Shellfish is an indicator of an allergy to the medium injected.
The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply:
A focussed cardiac assessment is directed towards assessing physiologic symptoms (cardiac pain, JVD, heart sounds and rate, and presence of diaphoresis) that provide immediate information regarding the client's condition, which is appropriate for the nurse to do at the beginning of each shift. After the physiological parameters have been evaluated the nurse can determine history of SOB and meds.
The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse’s instructions? Select all that apply:
Healing of venous stasis ulcers in dependent on relieving the venous congestion in the extremity. Compression devices and elevation of the extremity are the most effective methods. The client should avoid standing for long periods since this increases venous stasis. Moist cool and/or warm packs are NOT used, but moist environment dressings are utilized. Dressings need to be changed as frequently as necessary because there may be excessive drainage.
A nurse knows the clinical manifestations of a client with Addison’s disease include which of the following? Select all that apply:
Addison’s disease is due to hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation is a classic sign. Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition.
A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.
A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?
The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.
A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply.
To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.
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