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NCLEX QUESTION TRAINER EXPLANATIONS TEST 4

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NCLEX QUESTION TRAINER EXPLANATIONS TEST 4 1. A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although th... e client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders? (1) 1. The nurse has just returned to the desk and has four phone messages to return. Which of the following messages should the nurse return FIRST? 2. A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure? 3. The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery. Which of the following symptoms would suggest to the nurse that the patient has fluid volume overload? 4. A woman has been recently diagnosed with systemic lupus and shares with the nurse, “I am thinking about getting pregnant, but I don’t know how I will be able to tolerate a pregnancy since I have lupus.” Which of the following responses by the nurse is BEST? 6. The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 7. A client received six units of regular insulin three hours ago. The nurse would be MOST concerned if which of the following was observed? 8. The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, “I just don’t feel good.” Which of the following actions, if taken by the nurse, is BEST? 9. The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive a similar “shot” before surgery. The nurse’s response should be based on an understanding that the preoperative medication given before a cesarean section 10. The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should 11. The nurse is preparing a five-year-old child for surgery. The nurse notes that the child’s parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 12. The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil? 13. A mother brings her two-year-old boy to the pediatrician’s office. Which of the following symptoms would suggest to the nurse that the child has strabismus? 14. A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 15. The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary? 1. “ 16. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 17. Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body? 18. The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to 19. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 20. A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following? ..........................................................CONTINUED................................................ [Show More]

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