NCLEX COMP BOOK REVIEW

A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which of the following is the most appropriate action? A. Remove the IV B. Apply a warm compress C. Check for blood return D. Measure the area of infiltration

A. Remove the IV Rationale: What the ? requires: consider the harmful effects of infiltration and determine the action to take Infiltration can be damaging to the surrounding tissue so removing the IV is essential to prevent further damage.

The nurse prepares to care for a client on contact precautions who has a hospital acquired infection caused by MRSA. The client has an abdominal would that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse would assemble which necessary protective items before entering the clients room. A. gloves and gown B. gloves, mask, and goggles C. gloves, mask, gown, and goggles D. gloves, gown, and shoe protectors

C. Gloves, mask, gown and goggles Rationale: What the ? requires: consider the methods of possible transmission of infection Option 3 is correct because splashes of infective materials can occur during wound irrigation or suctioning of tracheostomy

The nurse is choosing age appropriate toys for a toddler. Which toy is the best for this age group? A. A puzzle B. Toy soldiers C. Large stacking blocks D. A card option with large pictures

C. Large stocking blocks Rationale: What the ? requires: principles of growth and development of a toddler Option 3 because toddlers like to master activities independently such as stocking blocks.

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure A. This will help only if I play music at the same time B. This will work for me only if I am alone in a quiet area C. I need to do this only when I lie down in case I fall asleep D. The best thing about this is that I can use it anywhere, anytime

D. The best thing about this is that I can use it anywhere, anytime Rationale: What the ? requires: the client understandings of guided imagery Option 4 because it can be done anytime, anywhere: some clients may use other relocation techniques or play music with it

The nurse has received the client assignment for the day. Which client would the nurse attend to first? A. The client who has a nasogastric tube attached to intermittent suction B. The client who needs to receive subcutaneous subcutaneous insulin before breakfast C. The client who is 2 days postoperative and is complaining of incisional pain D. The client who has a blood glucose level of 50 mg/dl and complains of blurred vision

D. The client who has a blood glucose level of 50 mg/dl and complains of blurred vision Rationale: What the ? requires: establish priorities by comparing the needs of each client and deciding which need is urgent. Option 4 has a low blood glucose level and symptoms are reflective of hypoglycemia. This client would be attended to first so that the treatment can be implemented.