EAQ NCLEX #2

Which methods qualify as alternative therapies for pain? -Prayer -Hypnosis -Medication -Aromatherapy -Guided imagery

-Prayer -Hypnosis -Aromatherapy -Guided imagery

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

-Problem solving approach

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? -Weight loss -Unusual fatigue -Dependent edema -Nocturnal dyspnea -Increase urinary output

-Unusual fatigue -Dependent edema -Nocturnal dyspnea

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

-She needs to push the PCA button whenever she needs pain medications

Which interventions would the nurse include in the plan of care for a client after total hip replacement? - Maintain the affected hip in the adduction position when moving the client - Pain control should include regularly scheduled analgesics as needed medications -The client should shit 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

- Pain control should include regularly scheduled analgesics as needed medications -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

A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? -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 the client sense of autonomy

-Client is able to self-administer pain-relieving medications as necessary -Decreases client dependency -Increases the client sense of autonomy

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

-Distended neck veins

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?" -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 one glass of wine or other alcoholic beverage at bedtime

-Leaving the bedroom when unable to sleep -Exercising in the afternoon rather than in the evening

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

-Naloxone administration

Which would the nurse do to understand the nature of a clients pain? -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 to not move as not to increase the pain

-Observe where the client locates the pain -Note whether the pain radiates to any other part of the body

Which are the best ways for the nurse to be protected legally? -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 clients nonadherence to the medical regimen

-Provide care within the parameters of the standards for nursing practice set by the state or province -Document consistently and objectively -Clearly document a clients nonadherence to the medical regimen

Which statements made by the patient indicate effective learning about management of low back pain? - "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"

- I should keep a check on my body weight - I should stop exercising if the pain becomes severe

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 2mL of sterile normal saline to dilute the heparin -Inject the medication into the vastus lateralis muscle in the thigh

-Avoid massaging the injection site after the injection

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

-By acknowledging that the pain is real and administering medication to relieve it

The nurse is formulating a teaching plan for a client recently diagnosed with DM2. Which interventions would the nurse include to decrease the risk of complications? -Examine the feet daily -Wear well-fitting shoes -Perform regular exercise -Power the feet after showering -Visit the primary health care provider weekly -Test bathwater with the toes before bathing

-Examine the feet daily -Wear well-fitting shoes -Perform regular exercise

Which action is the nurses responsibility when administering prescribed opiod analgesics? -Count the clients respirations -Document the intensity of the clients 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 clients toilet before leaving the room if the medication is refused

-Count the clients respirations -Document the intensity of the clients pain -Verify the number of doses in the locked cabinet before administering the prescribed dose

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 clients immediate nutritional needs? -Low in fat and vitamin D -High in calories and fiber -Low is residue and bland -High in protein and Vit C

-High in protein and Vit C

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

-Collaborate with a dietitian to obtain a special diet chart for the client

A client who had an AKA to the L 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 crutches

-Determine whether the client has ever used crutches

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

-Modifying the home environment to prevent accidents

A pain scale of 1 to 10 is used by the nurse to assess a clients degree of pain. The client rates the pain as an 9 before receiving an analgesic and a 7 after being medicated. Which conclusion would the nurse make regarding the clients response to pain medication? -The client has 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

-The medication is not adequately effective

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

-Tissue ischemia

Then nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the clients temperature. Which step is the nurse doing? -Validation -Assessment -Interpretation -Document

-Validation

Which finding in a client with pulmonary edema requires the most rapid action by the nurse? -weak, rapid pulse -oxygen saturation 82% -BP 99/54 mmHg -Crackles throughout both lungs

-oxygen saturation 82%

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

-Hypokalemia

Which nursing interventions would the nurse implement to promote sleep for a client in a health care setting? -Restrict visitors -Reduce lighting -Provide activities during the day -Decrease the sounds of the infusion alarms -Increase the dosage of pain prescriptions at night

-Reduce lighting -Provide activities during the day

Which information would the registered nurse provide to a student nurse about the importance of nursing documentation for risk management? - "A nurse 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 clients health" -"In case an occurrence report is filed, nurses would enter the information in the clients chart -Nurses would always document the primary health care providers responses whenever they are contacted

- "A nurse documentation is the evidence of care that a client receives" -"The nurse would note assessments and significant changes in the clients health" -Nurses would always document the primary health care providers responses whenever they are contacted

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

-Can you describe your pain to me?

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 clients pulse rate is 90 beats/min -The client has a body temp of 39C 102.2F

-The client seems restless

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the clients plan of care? -ask the client about the acceptable level of pain -Eliminate all activities that precipitate pain -Administer the pain medications regularly around the clock -Use a different pain scale each time to promote patient education -Assess the clients pain every 15 minutes

-ask the client about the acceptable level of pain -Administer the pain medications regularly around the clock