NCLEX Exam 2

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. Which step is the nurse doing? Validation Assessment Interpretation Documentation

1

Which question asked by the nurse is most appropriate to assess the nature of the client's pain? Can you describe your pain to me?' 'Is your pain associated with movement?' 'Can you rate your pain on a scale of 0 to 10?' 'Do you notice your pain worsening with any activity?'

1

Which written statement made by the nurse while documenting factual records indicates a need for additional training? 'The client seems restless.' 'The client states, 'I am worried.'' 'The client's pulse rate is 90 beats/min.' 'The client has a body temperature of 39°C (102.2°F).'

1

Which action is the nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. One, some, or all responses may be correct. Count the client's respirations. Document the intensity of the client's pain. Withhold the medication if the client reports pruritus. Verify the number of doses in the locked cabinet before administering the prescribed dose. Discard the medication in the client's toilet before leaving the room if the medication is refused.

1,2,4

Which methods qualify as alternative therapies for pain? Select all that apply. One, some, or all responses may be correct. Prayer Hypnosis Medication Aromatherapy Guided imagery

1,2,4,5

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. One, some, or all responses may be correct. Client is able to self-administer pain-relieving medications as necessary Amount of medication received is determined entirely by the client Decreases client dependency Relieves the nurse of monitoring the client Increases client sense of autonomy

1,2,5

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. Ask the client about the acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes.

1,3

The nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications? Select all that apply. One, some, or all responses may be correct. Examine the feet daily. Wear well-fitting shoes. Perform regular exercise. Powder the feet after showering. Visit the primary health care provider weekly. Test bathwater with the toes before bathing.

1,3,4

Which information would the registered nurse provide to a student nurse about the importance of nursing documentation for risk management? Select all that apply. One, some, or all responses may be correct. A nurse's documentation is the evidence of care that a client receives.' 'Nurses' notes would not be given to attorneys in the event of a lawsuit.' 'The nurse would note assessments and significant changes in the client's health.' 'In case an occurrence report is filed, nurses would enter the information the client's charts.' 'Nurses would always document the primary health care providers' responses whenever they are contacted.'

1,3,5

Which nursing interventions would the nurse implement to promote sleep for a client in a health care setting? Select all that apply. One, some, or all responses may be correct. Restrict visitors. Reduce lighting. Provide activities during the day. Decrease the sounds of the infusion alarms. Increase the dosage of pain prescriptions at night.

2,3

A client who had an above-the-knee amputation of the left leg plans to use crutches until a prosthesis is fitted. Which action would the nurse take first? Demonstrate the swing-through crutch walking gait. Determine whether the client has ever used crutches. Introduce the client to another client who is using crutches. Provide a pamphlet that has information about using crutche

2

A pain scale of 1 to 10 is used by the nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. Which conclusion would the nurse make regarding the client's response to pain medication? The client has a low pain tolerance. The medication is not adequately effective. The medication has sufficiently decreased the pain level. The client needs more education about the use of the pain scale

2

After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understand instructions about the PCA pump? I'll make sure that she pushes the PCA button every 6 minutes.' 'She needs to push the PCA button whenever she needs pain medication.' 'I'll have to wake her up on a regular basis so she can push the PCA button.' 'I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping.'

2

To prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ? Administer the injection via the Z-track technique. Avoid massaging the injection site after the injection. Use 2 mL of sterile normal saline to dilute the heparin. Inject the medication into the vastus lateralis muscle in the thigh.

2

Which finding in a client with pulmonary edema requires the most rapid action by the nurse? Weak, rapid pulse Oxygen saturation 82% Blood pressure 99/54 mm Hg Crackles throughout both lungs

2

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary outpu

2,3,4

Which would the nurse do to understand the nature of a client's pain? Select all that apply. One, some, or all responses may be correct. Cover the area of discomfort. Observe where the client locates the pain. Refrain from touching the area of tenderness. Note whether the pain radiates to any other part of the body. Instruct the client not to moves so as not to increase the pain.

2,4

Which are the best ways for the nurse to be protected legally? Select all that apply. One, some, or all responses may be correct. Ensure that a therapeutic relationship with all clients has been established. Provide care within the parameters of the standards for nursing practice set by the state or province. Carry at least $100,000 worth of liability insurance. Document consistently and objectively. Clearly document a client's nonadherence to the medical regimen.

2,4,5

Which interventions would the nurse include in the plan of care for a client after total hip replacement? Select all that apply. One, some, or all responses may be correct. Maintain the affected hip in the adduction position when moving the client. Pain control should include regularly scheduled analgesics and as needed medications. The client should sit in a chair at the height to encourage flexion of the hip joint. Frequent neurovascular assessment should be done and compared with the unaffected side. When turning, the client should be log rolled to prevent the leg from falling forward or backward

2,4,5

Which element would the nurse focus on when teaching crutch-walking to a client who has a casted leg fracture Establishing a schedule for pain medication Maintaining a fixed schedule of daily activities Modifying the home environment to prevent accidents Understanding that a more sedentary lifestyle is necessary

3

A client who receives morphine by patient-controlled analgesia has a respiratory rate of 6 breaths/minute. Which intervention is needed? Nasotracheal suction Mechanical ventilation Naloxone administration Cardiopulmonary resuscitation

3

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain? By withholding the medication to help prevent addiction By stating that the limb has been removed and that the pain is psychological By acknowledging that the pain is real and administering medication to relieve it By explaining that the phantom limb sensation will subside within a few more days

3

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess? Proteinemia Contractures Tissue ischemia Thrombus formation

3

Which statements made by the client indicate effective learning about management of low back pain? Select all that apply. One, some, or all responses may be correct 'I should sleep in a prone position. 'I should sleep with my legs out straight.' 'I should keep a check on my body weight.' 'I should stop exercising if the pain becomes severe.' 'I should exercise by leaning forward without bending the knees.'

3,4

Which strategies would the nurse teach a client who says, 'I have been having trouble sleeping and feel wide awake as soon as I get into bed'? Select all that apply. One, some, or all responses may be correct. Eating a heavy snack near bedtime Reading in bed before shutting out the light Leaving the bedroom when unable to sleep Drinking a cup of warm coffee with milk at bedtime Exercising in the afternoon rather than in the evening Drinking at least 1 glass of wine or other alcoholic beverage at bedtime

3,5

A client who has received tap water enemas until clear is at risk for developing which complication? Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia

4

An abscess develops in an obese adult after abdominal surgery. The wound is healing by secondary intention. Which diet would the nurse expect the health care provider to prescribe to meet this client's immediate nutritional needs? Low in fat and vitamin D High in calories and fiber Low in residue and bland High in protein and vitamin C

4

The nurse notices that a diabetic client is consuming chocolate brought by a family member. Which action would the nurse perform to adhere to the principle of autonomy? Ask if the client has a weakness for sweets. Request that the client refrain from eating chocolates. Explain the consequences of eating chocolates to the client. Collaborate with a dietitian to obtain a special diet chart for the client

4

Which finding would the nurse expect when caring for a client with right-sided heart failure? Oliguria Pallor Cool extremities Distended neck veins

4

Which is the primary focus of the nurse when providing evidence-based care to the client? Practice trends Research studies Clinical experience Problem-solving approach

4