Nurs 4 - NCLEX EAQ's - Nursing Process: Implementation (2022)

A client with epilepsy is prescribed phenytoin for seizure control. Which instruction about phenytoin will the nurse provide during discharge teaching? 1 "Antiseizure medications will probably be continued for life." 2 "Phenytoin prevents any further occurrence of seizures." 3 "This medication needs to be taken during periods of emotional stress." 4 "Your antiseizure medication usually can be stopped after a year's absence of seizures."

1 - "Antiseizure medications will probably be continued for life." Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite medication therapy; the dosage may need to be adjusted. A therapeutic blood level must be maintained through consistent administration of the medication irrespective of emotional stress. Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiological condition.

The nurse is reviewing the procedure for intervention if a fire occurs. Which interventions would the nurse include in the procedure if a fire occurs that relate to the acronym RACE? Select all that apply. One, some, or all responses may be correct. 1 Activate the alarm. 2 Alert the local fire department. 3 Remove all clients from the area. 4 Evaluate all interventions provided. 5 Release the pin in the fire extinguisher. 6 Confine the fire by closing doors and windows.

1 - Activate the alarm. 3 - Remove all clients from the area. 6 - Confine the fire by closing doors and windows. The acronym RACE stands for Remove all clients from immediate danger, Activate the alarm, Confine the fire by closing doors and windows, and Extinguish the fire with an appropriate fire extinguisher. The acronym does not include alerting the local fire department or releasing the pin from the fire extinguisher.

Which population would the nurse include in a community education session on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct. 1 Adolescents 2 Homosexual men 3 Transgender clients 4 Multiple sex partners 5 Intravenous drug users

1 - Adolescents 2 - Homosexual men 3 - Transgender clients 4 - Multiple sex partners 5 - Intravenous drug users Adolescents, homosexual men, transgender clients, and those with multiple sex partners are at high risk for STIs. Intravenous drug users are also high risk and in need of education on STIs, as they are at particular risk for transmitting or contracting human immunodeficiency virus (HIV) through needle sharing.

Which is the best nursing intervention to support a hospitalized child's nutrition who is apathetic toward eating? 1 Asking the parents to visit at mealtimes 2 Having a nursing assistant feed the child 3 Providing diversional activity at mealtimes 4 Eliminating the child's between-meal snacks

1 - Asking the parents to visit at mealtimes Dinner is frequently a family activity. Having the parents visit during meals may provide the child with additional emotional, social, and physical support, resulting in improved nutritional intake. The child will be resentful if fed by a staff member. Providing diversional activity at mealtimes may further inhibit the child's nutritional intake. Eliminating the child's between-meal snacks may not influence the child's overall intake; snacks may be preferred and will provide a source of nutrition.

A client who takes rifampin tells the nurse, "My urine looks orange." Which action would the nurse take? 1 Explain that this is expected. 2 Check the liver enzymes. 3 Ask the provider to order a urinalysis. 4 Ask what foods were eaten.

1 - Explain that this is expected. Rifampin causes a reddish-orange discoloration of secretions such as urine, sweat, and tears. Although liver enzymes should be monitored because of the risk of hepatitis, this action is not addressing the client's statement. A urinalysis is not indicated for an anticipated finding. The medication, not food, is responsible for the urine color.

Which initial action would the nurse take to provide a therapeutic environment for a client who is withdrawn and reclusive? 1 Foster a trusting relationship. 2 Administer medications on time. 3 Involve the client in a group with peers. 4 Remove the client from the family home.

1 - Foster a trusting relationship. Initially, the nurse would foster a trusting relationship. An interpersonal relationship based on trust must be established before a client can be helped. Administering medications on time is an important part of the treatment and care, but it is of lesser importance than a trusting relationship. Socialization comes at a later point in therapy. There is nothing to indicate a need to remove the client from the home.

Which level of trauma center provides a full continuum of care for the trauma client? 1 Level I 2 Level II 3 Level III 4 Level IV

1 - Level I Level I trauma centers are likely an urban academic center that provides the full continuum of care for the trauma client and conducts research for trauma center verification. Level II trauma centers provide care to most trauma clients and are located in the community hospital. Level III trauma centers stabilize and transfer trauma clients from the community hospital setting. Level IV trauma centers are likely rural with basic support that transfers out to a higher-level care center.

Which is a consequence on the neonate of maternal smoking during pregnancy? 1 Low birth weight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions

1 - Low birth weight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in an SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.

The parents of a child with juvenile idiopathic arthritis are investigating other therapies to use with medications. Which therapy would the nurse recommend? 1 Physical therapy 2 Speech therapy 3 Nutritional therapy 4 Behavioral therapy

1 - Physical therapy A physical therapist can prescribe an exercise protocol to keep the joints as mobile as possible; a routine can be developed to help the child alleviate morning stiffness. There is no evidence that speech therapy is needed at this time. Although nutrition is an appropriate part of therapy, it is the physical therapy program that can most directly influence movement. Behavioral therapy is referent only to special circumstances when the behavior needs warrant.

Which action by a 70-year-old female client would best limit further progression of osteoporosis? 1 Taking supplemental calcium and vitamin D 2 Increasing the consumption of eggs and cheese 3 Taking supplemental magnesium and vitamin E 4 Increasing the consumption of milk products

1 - Taking supplemental calcium and vitamin D Research demonstrates that women past menopause need at least 1500 mg of calcium a day, which is almost impossible to obtain through dietary sources because the average daily consumption of calcium is 300 to 500 mg. Vitamin D promotes the deposition of calcium into the bone. Consumption of eggs and cheese does not contain adequate calcium to meet requirements to prevent osteoporosis; these foods do not contain vitamin D unless fortified. If large amounts of magnesium are present, calcium absorption is impeded because magnesium and calcium absorption are competitive; vitamin E is unrelated to osteoporosis. Milk and milk products may not be consumed in quantities adequate to meet requirements to prevent osteoporosis.

A client reports feeling nauseated immediately after cataract surgery. Which action would the nurse take? 1 Provide some dry crackers to eat. 2 Administer the prescribed antiemetic. 3 Explain that this is expected after surgery. 4 Encourage deep breathing until the nausea subsides.

2 - Administer the prescribed antiemetic. An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. Aggressive intervention is required rather than dry crackers. Explaining that this is expected after surgery is not helpful in avoiding vomiting. Deep breathing will not minimize nausea; aggressive intervention is required to prevent vomiting.

Which leukocytes would the nurse include when teaching about antibody-mediated immunity? Select all that apply. One, some, or all responses may be correct. 1 Monocyte 2 Memory cell 3 Helper T cell 4 B-lymphocyte 5 Cytotoxic T cell

2 - Memory cell 4 - B-lymphocyte Memory cells and B-lymphocytes are involved in antibody-mediated immunity. Monocytes are involved in inflammation. Helper T cells and cytotoxic T cells are involved in cell-mediated immunity.

Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1 Encouraging fluids 2 Monitoring for seizures 3 Measuring abdominal girth 4 Checking for pupillary reactions

2 - Monitoring for seizures Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

In which role does the nurse oversee the budget of a specific nursing unit or agency? 1 Nurse educator 2 Nurse manager 3 Nurse researcher 4 Nurse practitioner

2 - Nurse manager The nurse manager is responsible for the budget of a specific nursing unit or agency. The nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and client education programs. The nurse researcher investigates problems to improve nursing care. The nurse practitioner provides health care to a group of clients usually in an outpatient, ambulatory care, or community-based setting.

While in the hospital's playroom a toddler suddenly has a nosebleed that leaves blood on the play table. Which is the nurse's first response in this situation? 1 Taking the child back to the room for care 2 Providing nursing care to stop the nosebleed 3 Calling the housekeeping department to clean the room 4 Securing a prescription for the blood to be tested for pathogens

2 - Providing nursing care to stop the nosebleed The nurse's priority is caring for the child. Once the child's problem has been resolved, the nurse may address the problem of the blood on the play table. The child's needs must be met immediately, even if the intervention must be performed in the playroom. Cleaning up the blood in the playroom is done after the child's immediate needs have been met. The hospital's protocol for the removal of the blood should be followed. Having the blood tested for pathogens is unnecessary unless the nurse or another individual has had direct contact with the blood; the hospital's protocol should be followed.

Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. 1 Palpate the chest and back for masses. 2 Question the client about shortness of breath. 3 Check the hematocrit and hemoglobin values. 4 Inspect the skin and nails for integrity and color. 5 Ask the client about color and quantity of sputum.

2 - Question the client about shortness of breath. 5 - Ask the client about color and quantity of sputum. Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.

When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? 1 Complete blood cell count 2 Serum potassium level 3 X-ray film of long bones 4 Blood cultures ×3

2 - Serum potassium level A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood cell count, x-ray film of long bones, and blood cultures ×3 will have no significance in the diagnosis of a potassium deficit.

Which toys would the nurse suggest to the parent of a 4-month-old infant to help promote the child's growth and development? 1 Push-pull toys 2 Soft squeeze toys 3 Nesting blocks and cups 4 Wooden hammer and pegboard

2 - Soft squeeze toys Soft, noisy squeeze toys are appropriate for a 4-month-old; the infant enjoys squeezing and hearing the sound of the squeaker. Push-pull toys are appropriate for a toddler 12- to 24-months of age. Nesting toys are appropriate for a toddler 16-months of age. Banging toys are appropriate for children from 12- to 18-months of age.

Which role does the federal government play in emergency preparedness? 1 Trains staff 2 Stockpiles critical equipment 3 Checks for completion of disaster drills 4 Ensures all organizations have fire drills

2 - Stockpiles critical equipment The U.S. government stockpiles critical equipment and supplies in the event of an emergency. The federal government does not train staff, check for completion of disaster drills, or ensure all organizations have fire drills.

Which intervention would the nurse recommend for post-cesarean gas pain? 1 Lying on the right side 2 Walking around the room 3 Using a straw when drinking water 4 Supporting the incision when moving

2 - Walking around the room Walking around as much as possible can help expel excess gas after a cesarean birth. The client also may be advised to lie on the left (not right) side and rock in a rocking chair. The client should avoid using a straw when drinking water or other fluids. Supporting the incision when moving relieves incisional pain, but does not promote expulsion of gas.

Which describes the role of the nurse in this situation when he or she informs the health care provider the client is requesting pain medication after surgery? 1 Educator 2 Manager 3 Advocate 4 Administrator

3 - Advocate The nurse acts as a client advocate by speaking to the primary health care provider on behalf of the client. The nurse acts as an educator while teaching the client facts about health and the need for routine care activities. The nurse manager uses appropriate leadership styles to create a nursing environment for client-centered care. The nurse administrator manages client care and delivery of specific nursing services within a health care agency.

Which preventive and primary care service provided by a community health center is most expensive? 1 Running errands 2 Health education 3 Disease management 4 Routine physical examinations

3 - Disease management Disease management is the most expensive service provided by community health centers. Running errands is relatively inexpensive, because the cost is the merely the cost of transportation. Health education and routine physical examinations are inexpensive and can usually stop complications of diseases, which prevents from having to "manage" diseases, leading to costly and expensive treatment.

A client has been prescribed lithium. Which intervention must be implemented while the client is on lithium therapy? 1 Restricting the client's daily sodium intake 2 Testing the client's urine specific gravity weekly 3 Regularly testing the serum medication level 4 Withholding the client's other medications for several days

3 - Regularly testing the serum medication level Lithium alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines. Because the range between therapeutic and toxic levels is very slim, the client's serum lithium level should be monitored closely. Sodium restriction may cause electrolyte imbalance and lithium toxicity. Weekly testing of the client's urine specific gravity is not necessary or useful. Withholding the client's other medications for several days may or may not be necessary; it depends on what the client is receiving; also, it requires a primary health care provider's prescription.

Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family of a terminally ill client who has died? 1 Primary health care provider 2 Pharmacist 3 Social worker 4 Occupational therapist

3 - Social worker The social worker on the interprofessional team helps the family members prepare for the client's death and during the grief and bereavement process. The nurse involves the social worker in consoling the family members in this situation. The primary health care provider and pharmacist may not be involved in consoling the family members after the client's death, nor may the occupational therapist be involved at this stage.

A registered nurse is explaining the Quality and Safety Education for Nurses (QSEN) competencies to a nursing student. Which information would the nurse provide about the competency teamwork and collaboration? 1 "Use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making." 2 "Understand that the client is the source of control and full partner when providing compassionate and coordinated care." 3 "Implement improvement methods to design and test changes to improve the quality and safety of the health care system." 4 "Work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care."

4 - "Work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care." According to the QSEN competency called teamwork and collaboration, the nurse would be able to work effectively within nursing and interprofessional teams, promoting open communication and shared decision-making to provide quality client care. According to the QSEN competency called informatics, the nurse would be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. This helps deliver optimal health care. As per the QSEN competency called patient-centered care, the nurse would be able to understand that the client is the source of control and full partner when the health care team provides compassionate and coordinated care. According to the QSEN competency called quality improvement, the nurse would be able to implement improvement methods to design and test changes to improve the quality and safety of the health care system.

While teaching a nursing student, the registered nurse says, "This is a study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable." Which type of research is described in the above statement? 1 Historical research 2 Evaluation research 3 Exploratory research 4 Experimental research

4 - Experimental research In experimental research, the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. In historical research, studies are designed to establish facts and relationships concerning past events. In evaluation research, studies test how well a program, practice, or policy is working. Exploratory research is an initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena.

Which method of contraception may provide adolescents with the longest duration of protection? 1 NuvaRing 2 Levonorgestrel implant 3 Spermicidal suppositories 4 Levonorgestrel intrauterine system

4 - Levonorgestrel intrauterine system The levonorgestrel intrauterine system is a T-shaped intrauterine system that releases levonorgestrel. It must be placed within 7 days of menses and provides protection up to 5 years. The NuvaRing, a flexible, soft, and transparent ring placed in the vagina, must be replaced every 3 weeks. The levonorgestrel implant is a small rod that provides protection for up to 3 years. Spermicidal suppositories are inserted into the vagina to kill sperm and provide protection for only a short duration.

The nurse in the clinic is obtaining the health history of a 16-year-old boy with a complaint of a thick urethral discharge. Which is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea? 1 Assessing the temperature for fever 2 Collecting a urine sample for a urinalysis 3 Drawing blood for a complete blood count 4 Obtaining a urethral specimen for a culture

4 - Obtaining a urethral specimen for a culture When the Gonococcus organism is present in the genitourinary tract of a male client, a culture of the urethral exudate provides a definitive diagnosis. Fever is not a specific diagnostic tool, because it occurs with other infections. Although urine may contain Gonococcus organisms, the urine dilutes the concentration; the organisms are more concentrated in the urethral discharge. The Gonococcus organism is in the genitourinary tract, not the blood; a complete blood count will not provide information with which to diagnose gonorrhea.

Which intervention is the most important for a young female client who was raped 3 days ago and continually talks about the trauma of being sexually assaulted? 1 Getting her involved with a rape therapy group 2 Remaining available and supportive to limit destructive anger 3 Exploring her feelings about men to promote future relationships 4 Providing a safe environment that permits the ventilation of feelings

4 - Providing a safe environment that permits the ventilation of feelings The client needs to be able to express her current feelings in a safe environment. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.

After a prolonged period in a regional hospital far from home to which the parents were unable to travel, an 18-month-old toddler becomes depressed, withdrawn, and apathetic. Eventually the toddler begins playing with toys and relating to others, even strangers. When the parents visit, the child ignores them. The parents tell the nurse that their child has forgotten them. How would the nurse explain the child's behavior? 1 The nurse suggests that they may be right and that their child will have to get to know them again. 2 This indicates approval of the staff and the child's understanding that they will not inflict bodily harm. 3 It reflects acceptance of the hospitalization and the experience will enhance their child's maturation. 4 This is typical behavior in toddlers who are separated from their parents for prolonged periods, and indicates that their child will need special attention from them.

4 - This is typical behavior in toddlers who are separated from their parents for prolonged periods, and indicates that their child will need special attention from them. The child has progressed to the third phase of separation anxiety, detachment or denial, in which there is a resignation to the loss of the parents and a superficial appearance of adjustment to the environment. Eighteen-month-old children do not forget their parents. The child's behavior indicates resignation, not acceptance or understanding of the situation. Toddlers who have parental support usually view staff members as unfamiliar, frightening, and often threatening. Acceptance of the hospitalization is often the mistaken interpretation of such behavior.