capstone NCLEX questions

A client with Meniere's disease is experiencing severe vertigo which instructions would we give the patient? A) increase fluid intake to 3000ml a day B) avoid sudden head movements C) lie still and watch television D) increase dietary sodium

B) avoid sudden head movements

a pt tells the nurse about having numbness from the back of the L buttock to the dorsum of the foot and big toes. The pt is scheduled for a laminectomy and the operative nurse consent form states, a L lumbar laminectomy of L3-L5. What should the nurse do next? A) have client sign the consent B) call the surgeon C) change the consent form D) review client hx

B) call the surgeon

A pt who has been treated for chronic open angle glaucoma for 5yrs asks the nurse, " How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG.... A) results from chronic eye inflammation B) causes increased intraoccular pressure C) lead to detachment of the retina D) is caused by decreased blood flow to the retina

B) causes increased intraoccular pressure

A male client underwent a lumbar fusion yesterday. Which nursing assessment should alert the nurse to the development of possible complication? A) lateral rotation of the head and neck B) clear yellowish fluid on the dressing C) use of standing position to void D) nonproductive cough

B) clear yellowish fluid on the dressing

The nurse observes the pt instill eye drops. The pt says, "I just try to hit the middle of my eyeball so the drops do not run out of my eye." The nurse explains to the client this his method may cause: A) scleral staining B) corneal injury C) excessive lacrimation D) systemic drug absorption

B) corneal injury

The RN is reviewing the physician's orders for a pt with Meniere's disease. Which diet should he/she most anticipate being prescribed? A) low cholesterol diet B) low sodium diet C) low carb diet D) low fat diet

B) low sodium diet

A pt with a ruptured intervertebral disc at L4-L5 stand with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating: A) motor changes B) postural deformity C) alteration of reflexes D) sensory changes

B) postural deformity

The nurse monitors the cardiac enzymes of the client who has severe chest pain. Which enzyme elevates and peaks most rapidly if the client experiences a MI? A) CKMB B) LDH C) AST D) LDL

A) CKMB

The clinic nurse counsels the client reporting low back pain. Which client statement requires follow up by the nurse? A) I work full time as a cashier at the local grocery store B) I sleep on a firm mattres C) I walk for 30min a day D) I sleep on my side with my knees and hips flexed

A) I work full time as a cashier at the local grocery store

The nurse cares for the pt reporting SOB and chest pain. The nurse assesses the pt and finds a 3rd heart sound, known as S3. The nurse identifies this sound as indicating what condition? A) MI B) aortic stenosis C) cardiomyopathy D) pericarditis

A) MI

The nurse is planning to teach the client with COPD how to cough effectively. Which of the following instructions should be included? A) Take 3 deep abdominal breaths, bend forward, and cough while saying the word "who" on exhalation B) lie flat on back splint the thorax take two breaths and cough C) take several rapid shallow breaths and cough forcefully D) assume a side lying position, extend arm over head and alternative deep breathing with coughing

A) Take 3 deep abdominal breaths, bend forward, and cough while saying the word "who" on exhalation

The ED nurse cares for the client experiencing a MI with no dysrhythmias. Which order does the nurse anticipate carrying out? SELECT ALL A) administer O2 B) establish an IV line C) monitor the EKG D) administer lidocaine E) administer aspirin F) insert a foley cath

A) administer O2 B) est. IV line C) monitor EKG E) administer aspirin

The nurse who is explaining the pathophysiology of COPD to a client includes the fact that alveolar destruction results in which manifestation? SELECT ALL A) decrease surface area for gas exchange B) increase dead space air C) development of pulmonary emoboli D) chronic dilation of bronchioles E) airway collapse related to loss of elasticity

A) decrease surface area for gas exchange E) airway collapse related to loss of elasticity

The nurse cares for the client reporting numbness in the left arm and intermittent upper sternal pressure that radiates to the neck. The pressure is relieved by rest. The client states,"I can't explain it by I feel like I'm about to die." Based on the available information, which nursing dx does the nurse select as most important? A) pain related to ischemia B) impaired kidney function related to decreased cardiac output C) potential ineffective breathing r/t fluid overload D) anxiety related to fear of death

A) pain related to ischemia

A labyrinthectomy can be performed to treat Meniere's. This procedure results in... A) permanent irreversible damage B) reduction in cerumen C) absence of pain D) temporary amnesia

A) permanent irreversible damage

The nurse is reviewing the CDC recommendations for vaccines. The pneumoccoal vaccine is recommended for which group? SELECT ALL A) pt who are immunocompromised B) smokers b/t 19-64 yr old C) newborns D) pts who are candidates for transplant E) MS pts

A) pts who are immunocompromised B) smokers b/t 19-64 yrs old E) MS pts

When assessing a 3yr old child a the clinic for a routine checkup which skill should the nurse expect to child to be able to perform. SELECT ALL A) ride a tricycle B) tie his or her shoes C) kick a ball forward D) use blunt scissors

A) ride a tricycle D) use blunt scissors

The nurse suctions a client's trach. The nurse lubricates the catheter with which material? A) sterile water B) mineral oil C) hydrogen peroxide D) water soluble lubricant

A) sterile water

To faciliate communication with a client who has a trach which nursing approach is best? A) tell the pt to nod their head to indicate yes and shake to their head to indicate no B) tell the pt to mouth words so the nurse can lip read C) have someone who knows the pt stay at the bedside to act as an interpreter D) ask the pt to anticipate needs and write them down

A) tell the pt to nod their head to indicate yes and shake to their head to indicate no

a women with a hx of chronic alcohol abuse is admitted to the obstetric unit in labor. When assessing the newborn, which of these findings would be consistent with a diagnosis of FAS. SELECT ALL A) thin upper lip B) small jaw C) excess nuchal skin D) small palpebral fissures E) hyper flexibility F) low set small eyes

A) thin upper lip B) small jaw D) small palpebral fissures

Meniere's disease is a disease that affects the hydraulic pressure within the inner ear. Accumulation of excessive pressure results in several symptoms such as.... SELECT ALL A) tinnitus B) vertigo C) fluctuating hearing loss D) exophthalmos related to increased IOP

A) tinnitus B) vertigo C) fluctuating hearing loss

a client who has a lumbar laminectomy with a spinal fusion is sitting in a chair. Which is the correct position for this client? A) with feet flat on the floor B) on a low footstool C) in any comfortable position with legs uncrossed D) on a high footstool so the feet are level with the chair seat

A) with feet flat on the floor

The nurse is caring for an older adult pt with a chronic respiratory disorder. Which interventions are best to use in caring for this patient? SELECT ALL A) provide rest periods b/t activities such as ambulation, meals and bathing B) place the pt in a supine position after meals to allow for rest C) schedule drug administration around the routine activities to increase adherence to drug therapies D) arrange chairs in strategic locations to allow the patient to walk and rest E) teach the pt to avoid getting the pneumococcal vaccine F) encourage the patient to have an annual flu vaccine

ANA DIDNT F*ING PUT AN ANSWER

Which statement is correct in the relationship of smoking cessation to the pathophysiology of COPD? A) smoking cessation completely reverses the damage to the lungs B) smoking cessation slows the rate of disease progression C) smoking cessation is an important therapy for asthma but not for COPD D) smoking cessation reverses the effects on the airway by not the lungs

B) smoking cessation slows the rate of disease progression

the nurse observes a student nurse suction in the right bronchus of a client via the tracheostomy. The nurse determines care is an appropriate if the student nurse places the pt's head in which position? A) the client's head is turned to the right B) the client's head turned to the left C) the client's head tilted forward toward the chest D) the client's head tilted backward even with the shoulders

B) the client's head turned to the left

Which assessment data indicates to the nurse that the pt recovering from an open cholecystectomy may require pain meds? A) the pt pulse is 65beats/min B) the pts has shallow respirations C) the pts bowel sounds are 20/min D) the pt uses a pillow to splint when coughing

B) the pts has shallow respirations

The HCP working in an immunization clinic is supervising the medical assistant during a flu vaccine administration. The HCP should question the immunization of which of the following pts scheduled to receive the vaccine? A) 32yr old man allergic to latex B) 76yr old women with hx of CHF C) 13yr old boy with allergy to eggs D) 65yr old man with hx of emphysema

C) 13yr old boy with allergy to eggs

How much bile would the nurse expect a t-tube to drain during the last 24hr after a cholecystectomy? A) 50-100ml B) 150-250ml C) 300-500ml D) 550-700ml

C) 300-500ml

Which of the following statements made by the pt dx with MS would alert the HCP that the pt requires additional instruction about the disease. SELECT ALL A) It's important for me to inspect my skin daily to make sure that there aren't any injuries B) regular exercise can help reduce fatigue and help improve my sense of balance C) I will avoid foods that are high in fiber to prevent problems with my bowels D) A hot bath in the evening will help my muscles and relieve pain

C) I will avoid foods that are high in fiber to prevent problems with my bowels D) A hot bath in the evening will help my muscles and relieve pain

The parent of a 9mo old brings the infant into clinic for a regular check up. The infant has receive no immunization. Which vaccines if prescribed would the nurse question? A) DTAP B) HIB C) MMR D) Flu

C) MMR

A pt requires an emergency tracheostomy. When caring for the trach, the nurse should suction which of the following actions? A) suction every hour B) clean the inner cannula after suctioning C) clean the site every 4 hours D) hyperextend the pt's neck to maintain patency

C) clean the site every 4 hours

When teaching the pt with Meniere's disease which of the instructions would the nurse give about vertigo? A) report dizziness immediately B) drive in daylight hours only C) get up slowly, turning the entire body D) change your position only with assistance

C) get up slowly, turning the entire body

A COPD pt's family asks the nurse what is the purpose of making the pt cough on routine basis. The nurse's best response is... A) we have to check the color and consistency of his sputum B) we don't want him to feel embarrassed when coughing in public so we actively encourage it C) it improves air exchange by increasing airflow in the large airways D) if he cannot cough, the Dr. may elect to do a tracheotomy

C) it improves air exchange by increasing airflow in the large airways

A client uses timolol maleate eye drops. The expected outcome of this drug is to control glaucoma by: A) constricting the pupils B) dilating the canal of schlemm C) reducing the aqueous humor formation D) improving the ability of the ciliary muscles to contract

C) reducing the aqueous humor formation

Which of these assessment findings should the HCP expect to identify as an early clinical characteristic of MS? A) muscle atrophy B) dementia C) vision loss D) clonus

C) vision loss

The nurse cares for the client dx with CAD. The client exercises 3x per week, but now experiences SOB and fatigue when exercising. The client asks the nurse, "Why can't I go to the gym anymore without feeling tired within 5 minutes?" Which is the nurse's best response? A) "The humidity in the air affects your heart's ability to function" B) "Your lungs are over-expanded, which makes it difficult to catch your breath" C) "You are exhausted from all the medical procedures you have been going through. Once you are rested, you will be able to exercise again" D) "Due to an inadequate blood supply to the heart, your heart is unable to meet your body's O2 needs during exercise"

D) "Due to an inadequate blood supply to the heart, your heart is unable to meet your body's O2 needs during exercise"

The nurse should assess the clients with chronic pain open-angle glaucoma for... A) eye pain B) excessive lacrimation C) colored light flashes D) decreasing peripheral vision

D) decreasing peripheral vision

A women in the first trimester of pregnancy drinks 8-10oz of alcohol daily. The nurse plans for the delivery of an infant who is... A) jaundiced B) dependent on alcohol C) healthy but underweight D) microcephalic and cognitively impaired

D) microcephalic and cognitively impaired

The pt undergoes a traditional cholecystectomy and returns from surgery with a T tube. To evaluate the effectiveness of the T-tube, the nurse should understand that the primary reason for the T-tube is to accomplish which of the following? A) promote wound drainage B) provide a way to irrigate the biliary tract C) minimize the passafe of bile into the duodenum D) prevent bile from the peritoneal cavity

D) prevent bile from the peritoneal cavity

After a cholecystectomy it is recommended that the pt follow a low fat diet at home. Which of the following foods would be most appropriate to include in a low fat diet. A) cheese omelet B) peanut butter C) ham salad sandwhich D) roast beef

D) roast beef

Which clinical manifestation should the nurse assess when a pt has acute angle closure glaucoma? A) a gradual loss of central vision B) acute light sensitivity C) loss of color vision D) sudden eye pain

D) sudden eye pain

The nurse is caring for a patient with MS and appropriately plans to.... A) teach the patient to avoid all forms of weight bearing exercise B) avoid the use of an eyepatch as this could cause further damage to vision C) encourage the pt to consume a low residue diet D) teach the pt how to inject medications as all MS medications are administered via SQ or IM injection

D) teach the pt how to inject medications as all MS medications are administered via SQ or IM injection

The outer cannula of a client's tracheostomy tube is accidentally expelled 36 hours after surgery. Which action does the nurse take first? A) contact the HCP B) cuts the tracheostomy neck ties C) insert the emergency out tube that is taped to the head of the bed D) ventilate the client using a manual resuscitation bag

D) ventilate the client using a manual resuscitation bag