NCLEX Simclex Review Final Exam Correct & Updated Questions and Answers_100% Already Graded A+

NCLEX Simclex Review Final Exam Correct & Updated Questions and Answers_100% Already Graded A+ A physician has ordered the nurse to remove a client's central line. The line is a percutaneous non-tunneled central venous catheter placed in the client's subclavian vein. Which of the following principles should the nurse consider with the removal of this central line? - CORRECT ANSWER-Assess the catheter after removal to ensure that the tip is intact Removal of a central line must be done very carefully to avoid complications such as bleeding, blood clots or an embolus. When the nurse removes the central line, she should inspect the tip of the catheter to ensure that it is intact, as there is a small chance that the catheter tip can break off, enter the bloodstream and caused an embolus. When the perioperative nurse assesses the client for surgery, the BMI is assessed as low. The nurse knows that which of the following could be a concern? Select all that apply. - CORRECT ANSWER-Body temp regulation, delayed wound healing, risk of pressure ulcers, increase in surgical complications The nurse is caring for a client who is newly diagnosed with multiple sclerosis. Which of the following is appropriate teaching for this client? - CORRECT ANSWER-"Make sure you're getting good fluid intake, around 2L/day" Multiple sclerosis (MS) can cause incontinence, and this is difficult to cope with. Many clients with MS will drink less to avoid episodes of incontinence, but this leads to dehydration and constipation. The client with MS must be taught to continue adequate fluid intake. A nurse is caring for a client complaining of pain. Which of the following critical thinking steps would the nurse utilize to respond to this situation? Select all that apply. - CORRECT ANSWER-Collect facts, identify, set priorities, evaluate the clients response A nurse must obtain a blood sample from a client's central line. The client had IV fluid infusing into the line and the nurse has already disconnected the infusion. Which of the following describes the next step of the nurse? - CORRECT ANSWER-Cleanse hub of catheter for 15 seconds A conscious or unconscious emotional response to a client based on the nurse's own inner needs and feelings is referred to as which of the following? - CORRECT ANSWER-Countertransference During the physical assessment of a comprehensive exam, the nurse tells a diabetic client about the necessity to undergo several tests to determine if the diabetes has caused complications. The nurse performs glucose testing, a foot exam, an ankle-brachial index, and checks the client's blood pressure. In addition to these tests, which type of exam should also be included to check for complications? - CORRECT ANSWER-Injection site inspection A provider has ordered a nurse to perform bladder irrigation on a client in the hospital. Which of the following describes a purpose of performing bladder irrigation in a client? Select all that apply. - CORRECT ANSWER-Decrease bleeding, clear blood clots, promote healing The nurse is caring for a client that has Hashimoto's thyroiditis. Which of the following symptoms should the nurse expect to see with this client? Select all that apply. - CORRECT ANSWER-Intolerance to cold, fatigue The nurse is caring for a client with depression who takes a selective serotonin reuptake inhibitor. The nurse knows these types of drugs include which of the following? Select all that apply. - CORRECT ANSWER-Fluoxetine, Paroxetine, Sertraline The nurse is caring for a client who presents to the emergency department with angina. Which of the following is the first action the nurse will take? - CORRECT ANSWER-Administer nitroglycerin 0.4 mg sublingual The first action the nurse will take out of the four choices is to administer a 0.4 mg sublingual nitroglycerin tab. A nurse works in the medical-surgical unit of the hospital and is performing safety checks on medical equipment. Which of the following is an example of a device factor that would contribute to an adverse event? Select all that apply. - CORRECT ANSWER-Faulty connecters on chest tube drainage system, hole in catheter tubing Which of the following is an element that describes pulsus bigeminus? Select all that apply. - CORRECT ANSWER-Alternating strong and weak pulses, a pulse that comes in after a strong one that is weak The nurse is caring for a client with a cardiac condition. The nurse knows that which of the following conditions put a client at risk for cardiogenic shock? Select all that apply. - CORRECT ANSWER-V tach, Myocardial Infarction, V-fib A nurse is preparing to discharge a client with bronchitis to home from the hospital. The nurse has the client demonstrate that he understands how to use his inhaler appropriately. After successfully demonstrating use of the inhaler, the nurse says, "You are confidently using that inhaler." This is an example of which type of therapeutic communication? - CORRECT ANSWER-Giving recognition that the client is one time competent An example of giving recognition is the following statement; "I noticed you took all your medications." This statement recognizes the client's accomplishments without giving an overt compliment, because compliments can sometimes be viewed as condescending. A nurse is caring for a client who visits a tanning bed several times each week. The client's skin is brown and has a leathery texture. The nurse provides teaching to the client about tanning bed use, and includes which of the following factors as part of teaching? Select all that apply. - CORRECT ANSWER-Tanning bed contains harmful UV rays No amount is safe in tanning bed A nurse is utilizing effleurage as part of non-pharmacological pain management for a client in labor. Which describes the techniques of effleurage? Select all that apply. - CORRECT ANSWER--The process is distracting from the pain of labor for the client Effleurage is a form of gentle massage to the abdomen or back that can be used during labor to distract the client and help her relax. -The nurse lightly massages the abdomen or back Effleurage is a type of massage. The nurse applies pressure with the fingertips as lightly or firmly as the client wants. -The process promotes relaxation and pain relief This relaxation technique is done by applying pressure with the fingertips so that the laboring woman derives the comfort and benefits of touch. The client directs how firm or light the pressure will be. The nurse is caring for a client who is in premature labor. The client is being started on indomethacin to stop contractions. Which of the following aspects of the client's medical history would cause the nurse to question this order? - CORRECT ANSWER-Multiple gastric ulcers Indomethacin is an NSAID and should not be used in clients with ulcers, because of the increased risk for bleeding.