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NCLEX-RN Exam Questions - Part 145
1. Goal setting for a client with Meniere - s disease should include which of the following?
A) Frequent ambulation
B) Prevention of a fall injury
C) Consumption of three meals per day
D) Prevention of infection
2. Which of the following physician - s orders would the nurse question on a client with chronic arterial insufficiency?
A) Neurovascular checks every 2 hours
B) Elevate legs on pillows
C) Arteriogram in the morning
D) No smoking
3. A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:
A) The risks of exposure of the visitor to infectious organisms is great.
B) Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
C) The client is at extreme risk of acquiring infections.
D) Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.
4. The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse - s action would be:
A) Call the physician and inform him that the client has expired.
B) Remind the husband that the physician wrote an order not to resuscitate.
C) Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
D) Call a code and proceed with cardiopulmonary resuscitation.
5. The nurse is in the hallway and one of the visitors faints. The nurse should:
A) Sit the victim up and lightly slap his face
B) Elevate the victim - s legs
C) Apply a cool cloth to the victim - s neck and forehead until he recovers
D) Sit the victim up and place the head between the knees
A) Frequent ambulation
B) Prevention of a fall injury
C) Consumption of three meals per day
D) Prevention of infection
2. Which of the following physician - s orders would the nurse question on a client with chronic arterial insufficiency?
A) Neurovascular checks every 2 hours
B) Elevate legs on pillows
C) Arteriogram in the morning
D) No smoking
3. A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion:
A) The risks of exposure of the visitor to infectious organisms is great.
B) Hospital regulations mandate that everyone in the facility adhere to appropriate codes.
C) The client is at extreme risk of acquiring infections.
D) Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.
4. The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse - s action would be:
A) Call the physician and inform him that the client has expired.
B) Remind the husband that the physician wrote an order not to resuscitate.
C) Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
D) Call a code and proceed with cardiopulmonary resuscitation.
5. The nurse is in the hallway and one of the visitors faints. The nurse should:
A) Sit the victim up and lightly slap his face
B) Elevate the victim - s legs
C) Apply a cool cloth to the victim - s neck and forehead until he recovers
D) Sit the victim up and place the head between the knees
1. Right Answer: B
Explanation: (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Menieres disease. (C) Adequate nutrition is important, but the emphasis in Menieres disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
2. Right Answer: B
Explanation: (A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
3. Right Answer: C
Explanation: (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
4. Right Answer: D
Explanation: (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
5. Right Answer: B
Explanation: (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
Explanation: (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Menieres disease. (C) Adequate nutrition is important, but the emphasis in Menieres disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
2. Right Answer: B
Explanation: (A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.
3. Right Answer: C
Explanation: (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
4. Right Answer: D
Explanation: (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
5. Right Answer: B
Explanation: (A) Sitting the client up defeats the goal of re-establishing cerebral blood flow. (B) Elevating the legs anatomically redirects blood flow to the cerebral area. (C) This strategy is a nice general comfort measure after the victim has regained consciousness. (D) This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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