NCLEX Prep Questions with complete solutions.

NCLEX Prep Questions with complete solutions.A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance? a) Alcohol b) Cannabis c) Cocaine d) Opioids d) Opioids Reason: Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation. The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally twice a day for: a) Insomnia. b) Headache. c) Anxiety. d) Orthostatic hypotension. d) Orthostatic hypotension. Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal) therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury. Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension. 00:17 01:22 A client who is 32 weeks pregnant presents to the emergency department with bright red bleeding and no abdominal pain. A nurse should first: a) perform a pelvic examination. b) assess the client's blood pressure. c) assess the fetal heart rate. d) order a stat hemoglobin and hematocrit. c) assess the fetal heart rate. Reason: The nurse should assess the fetal heart rate for distress or viability. She shouldn't attempt to perform a pelvic examination because of the possibility of placenta previa, which presents as bright red bleeding without abdominal pain. The nurse should assess the client's blood pressure after attempting to hear fetal heart tones. Ordering a hemoglobin and hematocrit is a physician intervention, not a nursing intervention. A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? a) Deep breathing b) Shallow chest breathing c) Deep, cleansing breaths d) Chest panting b) Shallow chest breathing Reason: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated. After being treated with heparin therapy for thrombophlebitis, a multiparous client who delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching? a) "I can take two aspirin if I get uterine cramps." b) "Protamine sulfate should be available if I need it." c) "I should use a soft toothbrush to brush my teeth." d) "I can drink an occasional glass of wine if I desire." c) "I should use a soft toothbrush to brush my teeth." Reason: Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? a) Administer insulin subcutaneously. b) Administer a bolus of glucose I.V. c) Provide frequent early feedings with formula. d) Avoid oral feedings. c) Provide frequent early feedings with formula. Reason: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification? a) Class I. b) Class II. c) Class III. d) Class IV. b) Class II. Reason: According to the New York Heart Association Cardiac Disease classification, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Classification identifies Class II clients as having cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits. The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend? a) Carcinoembryonic antigen (CEA) test after age 50 b) Proctosigmoidoscopy after age 30 c) Annual digital examination after age 40 d) Barium enema after age 20 c) Annual digital examination after age 40 Reason: The American Cancer Society recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a screening test. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates: a) Absence of nausea and vomiting. b) Passage of mucus from the rectum. c) Passage of flatus and feces from the colostomy. d) Absence of stomach drainage for 24 hours. c) Passage of flatus and feces from the colostomy. Reason: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Absence of nausea and vomiting is not a criterion for judging whether or not gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: a) Perform the procedure safely and correctly. b) Critique the nurse's performance of the procedure. c) Explain all steps of the procedure correctly. d) Correctly answer a posttest about the procedure. a) Perform the procedure safely and correctly. Reason: The nurse should judge that learning has occurred from evidence of a change in the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates acquisition of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill. The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following? a) Contact the client's audiologist. b) Cleanse the hearing aid ear mold in normal saline. c) Irrigate the ear canal. d) Check the hearing aid's placement. d) Check the hearing aid's placement. Reason: Inadequate amplification can occur when a hearing aid is not placed properly. The certified audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal is done to remove impacted cerumen or a foreign body. The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should: a) Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression. b) Check respirations in 30 minutes because the effects of morphine will have worn off by then. c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. d) Monitor respirations each time the client receives morphine sulfate 10 mg I.M. c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. Reason: The nurse should monitor the client's respirations closely for 4 to 6 hours because naloxone has a shorter duration of action than opioids. The client may need repeated doses of naloxone to prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the client's respiratory rate will be necessary. The client's dosage of morphine will be decreased or a new drug will be ordered to prevent another instance of respiratory depression.