Readiness-Nclex questions style

Correct Answer:4, 5 A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply. 1. "The exercises will help reduce backaches." 2. "The exercises will help prevent ankle edema." 3. "The exercises will help prevent urinary tract infections." 4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 5. "The exercises will help strengthen the muscles that support the bladder and urethra."

Correct Answer:4, 5

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

Correct Answer: 1,2,3

Correct Answer: 1,2,5 The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

Correct Answer: 1,2,5

Correct Answer: 1,4,5,6 The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. 1. Chills 2. Fatigue 3. Sleepiness 4. Chest pain 5. Lower back pain 6. Difficulty breathing

Correct Answer: 1,4,5,6

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply. 1. A bulging anterior fontanel 2. A depressed anterior fontanel 3. A soft and flat anterior fontanel 4. A triangular-shaped anterior fontanel 5. A triangular-shaped posterior fontanel 6. Size of posterior fontanel is 4 cm by 6 cm.

Correct Answer: 3, 5

The nurse listens to report about a newly admitted client who has a skin ulcer that's tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) A. Place the client in a single room B. Keep all equipment in the client's room for his/her sole use C. Keep the door to the room closed, with a notice for visitors D. Perform hand hygiene after direct contact with the client and before leaving the room E. Wear mask when providing routine care to the client

The correct answer is A, B, C, D : Contact precautions are recommended in acute care settings for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care.

The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) A. 72 year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy B. 46 year-old with end stage liver disease, on a wait list for a donor organ. C. 8 year-old client with acute myelogenous leukemia, for whom all treatment options have failed D. 91 year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury

Answers Correct A, C, D Hospice care provides services for clients who are at the end of their life, usually with less than 6 months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care

The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) A. Ability to take medications B. Ability to eat independently/feed self D. Ability to bathe self E. Ability to cook meal

Answers Correct A, C, E Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment

A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.) A. Reconciliation of medications B. Client health status C. Family preferences D. Poor communication among providers E. Excellent primary care.

Answers Correct B, C, D Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care.

The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.) A. Trace amount of serosanguineous drainage on the groin dressing B. Pale color of the affected limb C. Capillary refill 6 seconds on the affected toes D. Nonpalpable pedal pulse on the affected limb E. Bruising or lump at the insertion site

Answers Correct B, C, D A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) A. Broiled or wood-grilled salmon B. Grilled sirloin steak C. Marinated cauliflower and broccoli D. Oranges E. Barbecued pork chops F. Acetaminophen

Answers Correct B, C, D Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

Which of the following methods are used to correctly identify a client? (Select all that apply.) A. Compare the person to a labeled photograph B. Ask clients to state their name C. Ask a family member or visitor D. Check the client identification bracelet

Answers Correct B, D, E Two pieces of identification are required prior to any procedure, including medication administration. Because client identification bracelets are not routinely used in long-term care facilities, nurses use a photograph to identify a resident. Asking the client or the client's family can be unreliable depending on the responder's cognitive and/or developmental status.

The MDS coordinator, who is a full time registered nurse, completes the minimum data set (MDS) for a new admission to a skilled nursing facility. Why does the nurse complete the MDS? (Select all that apply.) A. It will be used to measure outcomes of nursing care B. It is required by the board of trustees It provides a standardized set of essential clinical and functional status measures. C. It provides a standardized set of essential clinical and functional status measures. D. It's used to direct the care that may be performed by nursing assistants E. It is required for all clients in a Medicare- or Medicaid-certified nursing facility

Answers Correct C, E The Minimum Data Set (MDS) is a standardized uniform comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law (P.L.100-203). It is a component of the federally-mandated Resident Assessment Instrument (RAI) and must be completed for any individual staying more than 14 days in that facility. The MDS is designed to help nursing homes thoroughly assess individuals in a standardized, comprehensive and reproducible manner; potential problems, strengths and preferences are identified using the MDS. The MDS cannot measure outcomes of care.

The nurse receives a telephone call from a health care provider who wants to give a telephone order for a client. Which of the following actions should the nurse take? (Select all that apply.) A. Begin the order with the abbreviation "P.O." to indicate that it was a "phone order" B. Request that the order is signed by the provider before implementation C. Ask a second nurse to listen on another extension while the order is being given D. Record the order word-for-word and sign the order E. Verify understanding by reading the order back to the provider before hanging up

Answers Correct D , E Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" because abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility

A client is diagnosed with rheumatoid arthritis (RA). Which types of drugs might the nurse expect to be ordered as a combination drug therapy regimen? (Select all that apply.) A. Glucocorticoids B. Diuretics C. Antimicrobial agents D. Biological-response modifiers E. Anti-inflammatory drugs

Answers Correct D,E Rheumatoid arthritis is a chronic, systemic autoimmune disorder that results in symmetric joint destruction. Research shows that multiple drug therapy is most effective in protecting against further destruction and promoting function. Analgesics and anti-inflammatory drugs are used. Disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate help slow or stop progression of RA. Biological response modifiers are used to help stop inflammation. Glucocorticoids can also be used for severe RA or when RA symptoms flare to ease the pain and stiffness of affected joints. Because RA is not an infectious disease, antimicrobials are ineffective. Although there is swelling in the joints, it is not fluid, so diuretics are not part of the treatment plan.

A 28 year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) A. Assess the airway B. Prepare for CT imaging of the head C. Position this client in high Fowler's position D. Assess vital signs and neurological function E. Assess the wound for presence of drainage or bruising on the head.

The correct answer is A, B, D, E Remember primary emergency trauma assessment using "A, B, C, D and E". The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache.

During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) A. The nurse has worked on the same unit for 5 years B. The nurse works in the intensive care unit (ICU) C. The nurse is sleep-deprived D. The nurse is interrupted when preparing the medication E. The unit is short-staffed

The correct answer is B, C, D, E There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients.

A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) A. Pneumococcal polysaccharide vaccine (PPSV23) B. Tetanus, Diphtheria, Pertussis vaccine (Tdap) C. Shingles vaccine D. Seasonal influenza vaccine E. Meningococcal conjugate vaccine (MCV4) F. Human papillomavirus (HPV) vaccine F. Human papillomavirus (HPV) vaccine

The correct answer is B, D, D, E, F Adults older than age 50 should get the shingles vaccine. The PPSC23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it.

There is an order to administer an intramuscular influenza vaccine to an adult. What actions should the nurse take prior to administration of the injection? (Select all that apply.) A. Record the client's reaction to the injection B. Provide the client with the federal Vaccine Information Statement (VIS) C. Record the site and time of injection D. Check the expiration date on the vaccination bottle E. Ask the client if she or he can eat eggs without adverse effects F. Record the manufacturer of the vaccine and lot number.

The correct answer is B, D, E Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the federal Vaccine Information Statement to the client. The nurse should also verify any allergies, particularly hypersensitivity to eggs, prior to administering the vaccine. Observing for a reaction to the injection and recording the site, time of injection, the manufacturer and lot number are performed after administering the medication.

The client is newly diagnosed with gastroesophageal reflux disease (GERD). Which statement made by the client indicates a need for further information about this disease? (Select all that apply.) A. "I'll be sure to wait a while after eating before I go exercise at the gym." B. "If I have heartburn, I'll take my omeprazole (Prilosec)." C. "I will drink more water and less cola and other carbonated beverages." D. "I can't wait to leave the hospital, so I can get a good cup of coffee." E. "I am going to enroll in a smoking cessation class." F. "A bedtime snack may help me to sleep better."

The correct answer is B, D,F GERD occurs as a result of gastric secretions being refluxed back up into the esophagus causing esophageal irritation and burning. This usually occurs because the lower esophageal sphincter is too relaxed. The client should eat meals several hours before lying down and give up late night snacks. Food and beverages that may trigger symptoms, such as caffeine and carbonated beverages, should be avoided. Proton pump inhibitors such as omeprazole take one to four days to work, and should not be used as needed for heartburn. Instead, they should be taken routinely to prevent symptoms. Rapid-acting antacids can be used as needed to help relieve heartburn. Avoiding tobacco and losing weight may also help improve heartburn