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NCLEX-RN PDF DEMO:
QUESTION NO: 1
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
A. Providing him with books, challenging puzzles, and games as diversionary activities
B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
C. Having a volunteer come in to sit with the client and to read him stories
D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Answer: B
Explanation:
(A) These activities could be frustrating for the client if he is having difficulty with problem solving and concentration. (B) Selfcare is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does little to help him develop coping skills. (D) This will helpto prevent skin irritation or breakdown related to immobility but will not help to prevent behavioral changes related to immobility.
QUESTION NO: 2
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during:
A. First trimester
B. Second trimester
C. Third trimester
D. Every trimester
Answer: A
Explanation:
(A) Organogenesis occurs in the first trimester. Fetus is most susceptible to malformation during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this time. (D) The dangerous period for fetal damage is the first trimester, not the entire pregnancy.
QUESTION NO: 3
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
A. Vitamin C
B. Vitamin B1
C. Vitamin D
D. Vitamin A
Answer: A
Explanation:
(A) Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. (B)
Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. (C) Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
QUESTION NO: 4
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
A. Teach her to completely clean the skin to remove all ointments and markings after each treatment
.
B. Teach her to cover broken skin in the treated area with a medicated ointment.
C. Encourage her to wear a tight-fitting vest to support her scapula.
D. Encourage her to avoid direct sunlight on the area being treated.
Answer: D
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose- fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
QUESTION NO: 5
On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate position for a client in pulmonary edema, which is:
A. High Fowler
B. Lying on the left side
C. Sitting in a chair
D. Supine with feet elevated
Answer: A
Explanation:
(A) High Fowler position decreases venous return to the heart and permits greater lung expansion so that oxygenation is maximized. (B) Lying on the left side may improve perfusion to the left lung but does not promote lung expansion. (C) Sitting in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubation and mechanical ventilation. If a client is sitting in achair when this deterioration happens, it will be difficult to intervene quickly. (D) The supine with feet elevated position increases venous return and will worsen pulmonary edema.
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Updated: May 27, 2022