NCLEX EAQ module 7 nursing roles and attributes

After the nurse has completed teaching about sclerotherapy for a client with varicose veins, which client statement indicates that more teaching is needed? Incorrect1 "I can eat and drink normally in the hours before the procedure." 2 "I will still need to wear compression stockings after the procedure." 3 "I can plan to take acetaminophen or ibuprofen for pain after the procedure." Correct4 "I should return to the clinic immediately if there is any swelling at the procedure site."

Correct4 "I should return to the clinic immediately if there is any swelling at the procedure site." Because sclerotherapy causes inflammation of the affected vein, swelling is expected and not a reason to return to the clinic. No general anesthesia is used for sclerotherapy, so clients may eat and drink normally. Ongoing use of compression stockings is recommended to prevent more varicosities from developing. There is usually minimal pain after sclerotherapy and mild analgesics such as acetaminophen or ibuprofen are adequate for pain control.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is performed. Postoperatively, how often and for how long would the nurse take the client's vital signs? 1 Every 15 minutes for 2 hours 2 Every 30 minutes for 4 hours 3 Every hour for 8 hours 4 Every 2 hours for 12 hours

Correct1 Every 15 minutes for 2 hours Every 15 minutes for 2 hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; 2 hours after the procedure, the vital signs can be taken every 30 minutes instead of every 15 minutes if the client is stable. Every hour for 8 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.

Which interpretation would the nurse make about a depressed client with mild suicidal ideation who has no plan, but has adequate family support and attends church regularly? 1 Should be at no risk for suicide 2 Warrants one-on-one observation 3 Warrants placement in a seclusion room 4 Should be reassessed at intervals regarding suicidal intent

4 Should be reassessed at intervals regarding suicidal intent The nurse would make the interpretation that the client should be reassessed at intervals regarding suicidal intent. Although this client is at risk for suicide and should be reassessed frequently, because the client has a support system and no plan, the risk is not as great as for someone with no support and a plan. Any client who has suicidal ideas is at risk for suicide, whether or not there is a plan, but a person with a plan is at a higher risk than a person without a plan. This client has no immediate plan and no history of suicide attempts; therefore, one-on-one observation is not indicated. A seclusion room is a last resort when a client is out of control and at risk for injuring others.

Furosemide has been prescribed as part of the medical regimen for a client with hypertension. Which client statement indicates a need for medication education? Correct1 "This can decrease my vitamin K level." Incorrect2 "I will take the medication in the morning." 3 "I will contact my health care provider if I notice muscle weakness." 4 "I plan to take the medication even when my blood pressure is normal."

Correct1 "This can decrease my vitamin K level." Furosemide can produce hypokalemia, not vitamin K deficiency. A well-balanced diet should provide all the necessary vitamins and nutrients. Further teaching is necessary. The morning is the desirable time to take furosemide; early administration prevents nocturia. The client's statement to call the health care provider at signs of muscle weakness is appropriate because muscle weakness may indicate hypokalemia. The client's response to take the medicine even when the blood pressure is normal demonstrates an understanding that the medication should be taken as prescribed, independent of how the client feels, because hypertension is often asymptomatic.

Which techniques would the nurse use when assessing a preschool-aged child? Select all that apply. One, some, or all responses may be correct. Correct1 Asking questions directly to the child Correct2 Asking the child to sit on the examination table Correct3 Having the child undress, leaving on the undergarments 4 Having the parent of the child leave the room for the duration of the assessment Asking the child whether he or she would like to have the respiratory or abdominal assessment done first

Correct1 Asking questions directly to the child Correct2 Asking the child to sit on the examination table Correct3 Having the child undress, leaving on the undergarments 4 Having the parent of the child leave the room for the duration of the assessment Correct5 Asking the child whether he or she would like to have the respiratory or abdominal assessment done first Developmentally appropriate assessment techniques for a preschool-aged child include asking questions directly to the child, asking the child to sit on the examination table, having the child undress but leave on undergarments, and giving the child a choice about the order of assessment. The child's parent is not asked to leave the room for the duration of the assessment for the preschool-aged client.

Which is the initial approach the nurse would use when teaching a pregnant woman about the foods she should be eating to promote healthy growth and development of her fetus? 1 Asking the client what she usually eats at each meal 2 Explaining to the client why spicy foods should be avoided 3 Instructing the client to add calories while continuing to eat a healthy diet 4 Providing the client with a list of foods for reference when planning meals

Correct1 Asking the client what she usually eats at each meal Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.

Which characteristic of O-negative blood explains why people with this blood type are classified as "universal donors"? 1 It does not have any of the antigens that can cause a reaction. 2 The donor can donate blood more frequently than other people. 3 More people have this blood type, so it is more universally available. 4 It is more frequently administered when compared with other blood types.

Correct1 It does not have any of the antigens that can cause a reaction. Type O Rh-negative red blood cells will not cause an antigen-antibody reaction in people with O, A, B, AB, Rh-positive, or Rh-negative blood; therefore, this type of blood can be administered "universally" to others. However, an exact match of blood type is preferred because there may be other factors in the donor's blood that can cause a reaction. People, regardless of their blood types, can donate blood approximately every 2 months. The availability of blood type does not affect the compatibility of donated blood with a recipient's blood. Although it is a common blood type, this is not why people with this type are considered universal donors.

Which recommendation is important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet? 1 Use lemon juice to season meat. 2 Put condiments on food to add flavor. 3 Include canned vegetables in meal preparation. 4 Drink carbonated beverages instead of decaffeinated coffee.

Correct1 Use lemon juice to season meat. Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Which topic would the nurse include in the postoperative care teaching? 1 Gastric suction 2 Oxygen therapy 3 Fluid restriction 4 Urinary catheter

Correct1Gastric suction After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions that allow healing at the site of anastomosis. Oxygen is not required unless the client experiences a complication necessitating its administration. An intravenous (IV) line to meet fluid needs and replace gastric losses is given to the average client. A urinary catheter may or may not be necessary.

A newly hired nurse is delegated the task of developing a care plan for a diabetic client who just returned from surgery after undergoing amputation of the leg. Which task in the care plan is inappropriate according to guidelines? 1 The registered nurse (RN) administering antidiabetic medications 2 Instructing the licensed practical nurse (LPN) to monitor vital signs 3 The RN assessing the client's blood glucose levels at regular intervals 4 Instructing the licensed practical nurse (LPN) to change the dressing at the amputation site

Correct2 Instructing the licensed practical nurse (LPN) to monitor vital signs The LPN's scope of practice includes monitoring vital signs in clients with a stable condition. Instructing the LPN to monitor the vital signs of a client in an acute condition is inappropriate according to the guidelines. Administering antidiabetic medications to a diabetic client who underwent amputation would be done by the RN because the condition of the client is acute. The RN is responsible for assessing the blood glucose levels of the client who underwent amputation. The LPN is instructed to change the dressing at the amputation site.

A client with schizophrenia is actively psychotic. Which medication will be the most helpful to manage the psychotic signs and symptoms? 1 Citalopram 2 Ziprasidone 3 Benztropine 4 Acetaminophen with hydrocodone

Correct2 Ziprasidone Ziprasidone is a neuroleptic that reduces psychosis by affecting the action of both dopamine and serotonin. Citalopram is a selective serotonin reuptake inhibitor antidepressant. Benztropine is an anticholinergic. Acetaminophen with hydrocodone is an opioid analgesic.Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. Which could be the cause for this condition? 1 Loss of elasticity of the lens 2 Impairment of the extraocular muscles 3 Obstruction of the aqueous humor outflow 4 Progressive degeneration of the center of the retina

Correct2Impairment of the extraocular muscles Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

The nurse is providing discharge teaching to a client who was hospitalized for exacerbation of rheumatoid arthritis. Which statement by the client indicates correct understanding of the treatment plan? 1 "I will plan to rest in bed for the next 2 weeks." 2 "I will only take my medications when I am having joint pain." 3 " I will reduce the number of exercise repetitions when I have pain." 4 "I will push off with my fingers rather than my palms to get out of bed."

Correct3 " I will reduce the number of exercise repetitions when I have pain." The amount of exercise and number of repetitions should be reduced to prevent further joint damage if the client is experiencing increased pain. Activity should be balanced with rest. Medications should not be discontinued without consulting the primary health care provider. Pushing off with fingers may cause further damage to the phalangeal joints.

Which injury would the nurse suspect in a young adult client who reports that a knee occasionally gives way, sometimes locks, and "clicks" when walking? 1 Cracked patella 2 Ruptured Achilles tendon 3 Torn cartilage 4 Stress fracture

Correct3 Torn cartilage These adaptations are consistent with torn cartilage; this injury is common among basketball players. A fractured patella will cause pain and usually manifests itself at the time of the injury. A ruptured Achilles tendon is painful and prevents plantar flexion of the foot; adaptations usually are manifested at the time of the injury. A stress fracture is associated with pain, not with a clicking or locking of the knee.

Before discharging an anxious client, which information about anxiety would the nurse teach the family? 1 Anxiety is a totally unique feeling and experience. 2 Apprehension is generalized to the total environment. 3 Fears results from conscious actions, thoughts, and wishes. 4 Anxiety is a pattern of emotional and behavioral responses to stress.

Correct4 Anxiety is a pattern of emotional and behavioral responses to stress. Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.

The nurse is conducting a health class for adolescents. Which modifiable risk factor is most closely associated with the development of coronary heart disease (CHD) in both men and women? 1 Opioid use 2 Cigarette smoking 3 Judicious alcohol intake 4 Moderate exercise program

2 Cigarette smoking Nicotine in cigarette smoke constricts blood vessels, including coronary arteries, which contributes to the occurrence of angina and CHD. Opioid use is not a risk factor for CHD. Judicious alcohol intake may promote relaxation, decreasing stress and limiting the development of CHD. Inactivity, not moderate exercise, is a risk factor for CHD. Exercise decreases hypertension, blood clotting, and heart rate. Exercise also increases metabolism, the plasma level of high-density lipoprotein cholesterol, and cardiac capillary blood flow.

For which side effects would the nurse monitor in the client receiving methyldopa for hypertension? 1 Xerostomia 2 Hemolytic anemia 3 Thrombocytopenia 4 Lupus-like syndrome

2Hemolytic anemia Methyldopa is used in the treatment of hypertension. It can be a precipitating factor in an autoimmune disease such as hemolytic anemia. Scopolamine transdermal, an anticholinergic, may cause dry mouth or xerostomia. Chemotherapy drugs, such as mycophenolate mofetil and azathiprine, can cause thrombocytopenia. Procainamide is an anti-arrhythmic agent that can induce the formation of antinuclear antibodies and cause a lupus-like syndrome.

Which action will the nurse take to prevent skin breakdown for a client who is on bed rest? 1 Massage the bony prominences. 2 Promote range-of-motion activities. 3 Maintain a sheepskin pad under the client. 4 Encourage the client to move in the bed as much as possible.

4 Encourage the client to move in the bed as much as possible. The client who is confined to bed should be encouraged to move in bed to prevent prolonged pressure on any one skin surface. Massaging bony prominences increases the risk of skin breakdown. Although sheepskin material allows air to circulate under the client, it does not prevent prolonged pressure. Range-of-motion exercises move joints to prevent contractures; they do not relieve prolonged pressure.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which suggestion by the nurse is an example of primary prevention? 1 "Engage in daily physical exercise." 2 "Get yearly physical examinations." 3 "Attend hypertension screening programs." 4 "Read about how to prevent diabetes complications."

Correct1 "Engage in daily physical exercise." Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.

Which medication would be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? 1 Atropine 2 Dopamine 3 Epinephrine 4 Norepinephrine

Correct1 Atropine Atropine should be listed as the antidote for nerve agent poisoning in the disaster plan for a terrorist attack. Nerve gases cause the client's system to be flooded with acetylcholine, which results in an overstimulation of the nerve cell. Atropine works by blocking the acetylcholine receptors. The receptors will not pick up the acetylcholine. Dopamine, epinephrine, and norepinephrine are not medications used to treat nerve agent poisoning.

The nurse leader is working on resolving conflicts between team members. Which action indicates that the nurse is involved in constructive conflict? 1 Deepening the differences in values 2 Making use of authentic communication 3 Diverting energy from a more important issue 4 Polarizing groups, which reduces intergroup cooperation

Correct2 Making use of authentic communication Making use of authentic or genuine communication may help in resolving conflict between team members. Deepening the differences in values and diverting the energy from an important issue are destructive conflicts that may result in negativity from conflict resolution. Polarizing the groups is a destructive aspect of conflict resulting in division of groups and weakening of relationships.

The nurse is teaching a client receiving peritoneal dialysis about the reason dialysis solution is warmed before it is instilled. Which information would the nurse share with the client? 1 It forces potassium back into the cells, thereby decreasing serum levels. 2 It adds extra warmth to the body because metabolic processes are disturbed. 3 It helps prevent cardiac dysrhythmias by speeding up removal of excess potassium. 4 It encourages removal of urea by preventing constriction of peritoneal blood vessels.

4 It encourages removal of urea by preventing constriction of peritoneal blood vessels. A warm temperature encourages the removal of serum urea by preventing constriction of peritoneal blood vessels so that urea, a large-molecular substance, is shifted from the body into the dialyzing solution. Heat does not affect the shift of potassium into the cells. The removal of metabolic wastes is affected in kidney failure, not the metabolic processes. Heating dialysis solution does not affect cardiac dysrhythmias.