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NCLEX-RN Exam Questions - Part 119
1. A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
A) 'He should remove the electrodes for bathing.'
B) 'Damage to his heart muscle will be recorded by the monitor.'
C) 'He is to keep a record of everything he does during the day.'
D) 'He is to refrain from activities that cause chest pain.'
2. To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
A) Dangle the client - s legs over the edge of the bed every shift.
B) Massage the client - s calves briskly every shift.
C) Keep the client - s legs extended and discourage any movement.
D) Have the client tighten and relax leg muscles several times daily.
3. A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
A) Encourage exercises in the unaffected extremities.
B) Encourage her to cross and uncross her legs.
C) Check neurological and circulatory status of the affected leg hourly.
D) Place a trochanter roll along the upper thigh of the affected leg.
4. A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
A) He should be on a high-fiber diet.
B) He should eat a low-residue diet.
C) He should drink minimal amounts of fluids.
D) He does not need to make any modifications.
5. A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
A) Place her under the radiant warmer
B) Dry her with blankets
C) Place her to her mother - s breast
D) Place her on a heated pad
A) 'He should remove the electrodes for bathing.'
B) 'Damage to his heart muscle will be recorded by the monitor.'
C) 'He is to keep a record of everything he does during the day.'
D) 'He is to refrain from activities that cause chest pain.'
2. To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
A) Dangle the client - s legs over the edge of the bed every shift.
B) Massage the client - s calves briskly every shift.
C) Keep the client - s legs extended and discourage any movement.
D) Have the client tighten and relax leg muscles several times daily.
3. A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
A) Encourage exercises in the unaffected extremities.
B) Encourage her to cross and uncross her legs.
C) Check neurological and circulatory status of the affected leg hourly.
D) Place a trochanter roll along the upper thigh of the affected leg.
4. A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
A) He should be on a high-fiber diet.
B) He should eat a low-residue diet.
C) He should drink minimal amounts of fluids.
D) He does not need to make any modifications.
5. A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to:
A) Place her under the radiant warmer
B) Dry her with blankets
C) Place her to her mother - s breast
D) Place her on a heated pad
1. Right Answer: C
Explanation: (A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
2. Right Answer: D
Explanation: (A) Dangling the clients legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the clients calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D)Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.
3. Right Answer: B
Explanation: (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint.(C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
4. Right Answer: A
Explanation: (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D)Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.
5. Right Answer: C
Explanation: (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
Explanation: (A) The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. (B) The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. (C) The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. (D) The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
2. Right Answer: D
Explanation: (A) Dangling the clients legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the clients calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D)Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.
3. Right Answer: B
Explanation: (A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint.(C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
4. Right Answer: A
Explanation: (A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D)Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.
5. Right Answer: C
Explanation: (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-to-skin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
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