NCLEX Clinical Reasoning and Strategy Exam Preparation 4 With Answers (150 Solved Questions)

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NCLEX 150 QUESTIONS ANSWERS AND CLINICAL REASONINGEXAM PREP # 41. A young adult who was in a motorcycle accident is brought to theemergency room with a closed head injury with suspected subduralhematoma. Although the client complains of a severe headache, he is alertand answers questions appropriately. The nurse would question which ofthe following orders?1. “Promethazine (Phenergan) 25 mg IM 3 h.”2. “Morphine sulfate 10 mg IM q3-4h.”3. “Docusate sodium (Colace) 50 mg PO bid.”4. “Ranitidine (Zantac) 50 mg IVPB q12h.”Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) H1 receptor blocker, used as an antiemetic(2) correct–narcotic analgesic, causes CNS and respiratory depression,contraindicated in headinjury because it masks signs of increased intracranial pressure(3) stool softener, used for an immobilized patient(4) H2 histamine antagonist, reduces acid production in stomach, prevents stressulcers2. The nurse has just returned to the desk and has four phone messages toreturn. Which of the following messages should the nurse return FIRST?1. A woman in her first trimester of pregnancy complaining of heartburn.2. A man complaining of heartburn that radiates to his jaw.3. A woman complaining of hot flashes and difficulty sleeping.4. A boy complaining of knee pain after playing basketball.Strategy: Determine the least stable client.(1) caused by reflux of gastric contents into esophagus, treatment is small frequentmeals, don’tconsume fluids with food, don’t wear tight clothing(2) correct–indicates chest pain, needs to seek medical attention immediately(3) caused by menopause, treat with hormone replacement therapy (HRT)(4) should treat with rest and ice3. A patient is admitted to the surgical unit with a diagnosis of rule outintestinal obstruction. The nurse is preparing to insert a Salem sump NGtube as ordered. In which of the following positions would it be BEST for thenurse to place this patient during the procedure?1. Head of bed elevated 30°–45°.2. Head of bed elevated 60°–90°.3. Side-lying with head elevated 15°.4. Lying flat with head turned to the left side.

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Strategy: Remember the positioning strategy.(1) not the best position(2) correct–facilitates swallowing and movement of tube through GI tract(3) not the best position(4) not the best position4. The nurse is monitoring the fluid status of a 63-year-old woman receivingIV fluids following surgery. Which of the following symptoms would suggestto the nurse that the patient has fluid volume overload?1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.2. Cool skin, respiratory crackles, pulse 86 and bounding.3. Complaints of a headache, abdominal pain, and lethargy.4. Urinary output 700 cc/24 h, CVP of 5, and nystagmus.Strategy: Determine how each answer choice relates to fluid volumeoverload.(1) indicates dehydration(2) correct–will see bounding pulse, elevated BP, distended neck veins, edema,headache, polyuria, diarrhea, liver enlargement(3) symptoms could be from causes other than volume overload(4) slightly reduced output, CVP would be elevated, normal CVP 4-10 mm/H2 O,involuntary eye movements not seen5. A woman has been recently diagnosed with systemic lupus and shareswith the nurse, “I am thinking about getting pregnant, but I don’t knowhow I will be able to tolerate a pregnancy since I have lupus.” Which of thefollowing responses by the nurse is BEST?1. “Most women find that they feel better when they are pregnant.”2. “How long have you been in remission?”3. “Women with lupus frequently have slightly longer gestations.”4. “It is best to become pregnant within the first six months of diagnosis.”Strategy: Answers are a mix of assessments and implementations. Does thissituation require assessment? Yes.(1) maternal morbidity and mortality are increased with SLE(2) correct–should be in remission for at least 5 months prior to conceiving(3) gestation not affected by SLE(4) recommended that a woman wait two years following diagnosis before conceiving6. The multidisciplinary team decides to implement behavior modificationwith a client. Which of the following nursing actions is of primaryimportance during this time?1. Confirm that all staff members understand and comply with the treatment plan.2. Establish mutually agreed upon, realistic goals.3. Ensure that the potent reinforcers (rewards) are important to the client.4. Establish a fixed interval schedule for reinforcement.

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Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) correct–to implement a behavior modification plan successfully, all staff membersneed to be included in program development, and time must be allowed fordiscussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff orclient during implementation of this program(2) not of primary importance in designing an effective behavior modificationprogram(3) not of primary importance in designing an effective behavior modificationprogram(4) not of primary importance in designing an effective behavior modificationprogram7. A client received six units of regular insulin three hours ago. The nursewould be MOST concerned if which of the following was observed?1. Kussmaul respirations and diaphoresis.2. Anorexia and lethargy.3. Diaphoresis and trembling.4. Headache and polyuria.Strategy: “MOST concerned” indicates a complication.(1) Kussmaul respirations are signs of hyperglycemia(2) not indicative of hypoglycemia(3) correct–regular insulin peaks in two to four hours; indicates hypoglycemia; giveskim milk(4) not indicative of hypoglycemia8. The nursing assistant reports to the nurse that a client who is one-daypostoperative after an angioplasty is refusing to eat and states, “I just don’tfeel good.” Which of the following actions, if taken by the nurse, is BEST?1. The nurse talks with the client about how he is feeling.2. The nurse instructs the nursing assistant to sit with the client while he eats.3. The nurse contacts the physician to obtain an order for an antacid.4. The nurse evaluates the most recent vital signs recorded in the chart.Strategy: Answers are a mix of assessments and implementations. Does thissituation require assessment? Yes. Is the assessment appropriate? Yes.(1) correct–assessment required; monitor for closure of vessel, bleeding,hypotension, dysrhythmias(2) assess cause of problem before implementing(3) assess cause of problem before implementing(4) more important to assess what is happening now

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9. The nurse prepares a 25-year-old woman for a cesarean section. Thepatient says she had major surgery several years ago and asks if she willreceive a similar “shot” before surgery. The nurse’s response should bebased on an understanding that the preoperative medication given before acesarean section1. contains a lower overall dosage of medication than is given before generalsurgery.2. contains reduced amounts of sedatives and hypnotics than are given beforegeneral surgery.3. contains reduced amounts of narcotics than are given before general surgery.4. contains medications similar in type and dosages to those given before generalsurgery.Strategy: Think about the action of the medications.(1) decreased dosage of narcotics are used(2) dosages of sedatives and hypnotics will be similar(3) correct–decreased so less narcotic crosses the placental barrier causingrespiratory depressionin the infant(4) dosages of narcotics are reduced10. The nurse is caring for an 11-year-old patient being treated for afractured right femur with balanced suspension traction with a Thomassplint and Pearson attachment. The nurse notes that the patient’s left leg isexternally rotated. The nurse should1. place a trochanter roll on the outer aspect of the thigh.2. perform resistive range of motion of the left leg.3. adduct and internally rotate the left leg.4. instruct the patient to maintain the left leg in a neutral position.Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) correct–holds hip in neutral position and leg in normal alignment, entire weight ofleg cannot be held by props placed below knee(2) exercise would not prevent future external rotation of the leg(3) adduct (add to midline of body) does not change external rotation, internalrotation is not beneficial, normal alignment is required(4) leg will externally rotate unless propped in proper alignment11. The nurse is preparing a five-year-old child for surgery. The nurse notesthat the child’s parents are divorced and have joint legal custody. Theinformed consent for surgery has been signed by the mother. Which of thefollowing actions by the nurse is BEST?1. Notify the physician.2. Inform surgery.3. Contact the father to obtain consent.4. Continue the child’s preoperative preparation.

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Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) no reason to notify the physician(2) no reason to call the OR(3) consent from either divorced parent is sufficient(4) correct–parent or legal guardian required to give informed consent prior tosurgical procedure12. The nurse is caring for clients on the neurology unit. What would be theMOST appropriate action for the nurse to take after noting that a clientsuddenly developed a fixed and dilated pupil?1. Reassess in five minutes.2. Check the client’s visual acuity.3. Lower the head of the client’s bed.4. Contact the physician.Strategy: Answers are a mix of assessments and implementations. Is this asituation that requires assessment or validation? No. Determine theoutcome of the implementations.(1) assessment, situation does not require validation(2) assessment, has symptoms of increased ICP(3) implementation, would increase the intracranial pressure(4) correct–implementation, fixed and dilated pupil represents a neurologicalemergency13. A mother brings her two-year-old boy to the pediatrician’s office. Whichof the following symptoms would suggest to the nurse that the child hasstrabismus?1. When the child draws, he places his head close to the table.2. The child rubs his eyes frequently.3. The child closes one eye to see a poster on the wall.4. The child is unable to see objects in the periphery of his visual field.Strategy: Think about each answer choice.(1) suggestive of refractive error, myopia (nearsightedness), able to see objects atclose range(2) suggestive of refractive error(3) correct–visual axes are not parallel so the brain receives two images(4) suggestive of cataracts or problem with peripheral vision14. A client is given morphine 6 mg IV push for postoperative pain.Following administration of this drug, the nurse observes the following:pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of thefollowing nursing actions is MOST appropriate?1. Allow the client to sleep undisturbed.2. Administer oxygen via facemask or nasal prongs.3. Administer naloxone (Narcan).4. Place epinephrine 1:1,000 at the bedside.

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Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) should be given Narcan for low respiratory rate(2) problem is low respirations, this may be administered after medication(3) correct–IV naloxone (Narcan) should be given to reverse respiratory depression;respiratory rateof 8 is too low and necessitates a nursing action(4) unnecessary15. The school nurse is teaching a group of preschool mothers about poisonprevention in the home. Which of the following statements, if made by amother to the nurse, indicates that further teaching is necessary?1. “I should have a bottle of Ipecac for each of my children.”2. “I should induce vomiting if my child swallows lighter fluid.”3. “Giving my child water or milk may help dilute the poison.”4. “Proper storage is the key to poison prevention in the home.”Strategy: “Further teaching is necessary” indicates an incorrect statement.(1) Ipecac is available in 30 cc vials, advise parents to have available full doses foreach child, doses range from 10 to 30 cc(2) correct–vomiting contraindicated when child ingests hydrocarbons due to dangerof aspiration(3) small amounts of water or milk may dilute toxins(4) store in locked cabinets16. The nurse is caring for a manic client in the seclusion room, and it istime for lunch. It is MOST appropriate for the nurse to take which of thefollowing actions?1. Take the client to the dining room with 1:1 supervision.2. Inform the client he may go to the dining room when he controls his behavior.3. Hold the meal until the client is able to come out of seclusion.4. Serve the meal to the client in the seclusion room.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) should remain in the seclusion room(2) should have meal at regular time(3) should have meal at regular time(4) correct–should eat at regular time; remain in the seclusion room for client’ssafety17. Which of the following nursing actions has the HIGHEST priority for ateenager admitted with burns to 50% of his body?1. Counseling regarding problems of body image.2. Maintain airborne precautions.3. Maintain aseptic technique during procedures.4. Encourage peers to visit on a regular basis.

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Strategy: Think “Maslow.”(1) psychosocial, not highest priority(2) physical, use standard precautions(3) correct–safety is a priority for the client who is at high risk for infection(4) psychosocial, important for an adolescent, but is not highest priority18. The home health care nurse is caring for a 30-year-old woman with typeI diabetes mellitus. The client has been maintained on a regimen of NPH andregular insulin and a 1,800-calorie diabetic diet with normal blood sugarlevels. Morning self-monitoring blood sugar (SMBG) readings the past twodays were 205 mg/dL and 233 mg/dL. The nurse expects the physician to1. reduce the client’s diet to 1,500 calorie ADA.2. order 3 additional units of NPH insulin at 10 PM.3. order an additional 10 units of regular insulin at 8 PM.4. eliminate the client’s bedtime snack.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) diet should not be reduced(2) correct–dawn phenomena, treatment is to adjust evening diet, bedtime snack,insulin dose,and exercise to prevent early morning hyperglycemia(3) peaks in 4–6 hours, would not prevent dawn phenomena(4) would adjust snack, not eliminate it19. After sustaining a closed head injury and numerous lacerations andabrasions to the face and neck, a five-year-old child is admitted to theemergency room. The client is unconscious and has minimal response tonoxious stimuli. Which of the following assessments, if observed by thenurse three hours after admission, should be reported to the physician?1. The client has slight edema of the eyelids.2. There is clear fluid draining from the client’s right ear.3. There is some bleeding from the child’s lacerations.4. The client withdraws in response to painful stimuli.Strategy: Think about how each answer choice relates to a head injury.(1) not priority(2) correct–indicates a rupture of meninges and presents a potential complication ofmeningitis(3) not priority(4) is not a change in assessment20. A psychiatric nurse is assigned to conduct an admission nursing historyon a new client. The admission should include which of the following?1. The nurse’s opinion regarding the mental and emotional status of the client.2. Data addressing the client’s emotional state.3. Data that address a biopsychosocial approach, including a family systemassessment.4. Specific data detailing the client’s mental status.

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Strategy: Think about each answer choice.(1) depends on opinions that are not based on a complete assessment(2) limits the degree of information that is obtained from the client(3) correct–complete nursing history includes biopsychosocial data; client’spsychosocial and physical status are evaluated along with an assessment of theclient’s family system and social support network; evaluation of the client’s cognitiveability is important during the physiological status assessment(4) is necessary information about mental status, but is also an incompleteassessment21. Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for aclient. The client is also to receive Stadol 2 mg IM. Before administeringthese medications, the nurse should1. obtain respirations and temperature.2. dilute with 9 ml of NS.3. draw the medications in separate syringes.4. verify the route of administration.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) should monitor blood pressure and heart rate for orthostatic hypotension;respiration and temperature are not as high a priority(2) inappropriate(3) correct–Compazine should be considered incompatible in a syringe with all othermedications(4) unnecessary22. The nurse is caring for clients in the student health center. A clientconfides to the nurse that the client’s boyfriend informed her that he testedpositive for hepatitis B. Which of the following responses by the nurse isBEST?1. “That must have been a real shock to you.”2. “You should be tested for hepatitis B.”3. “You’ll receive the hepatitis B immune globulin (HBIG).”4. “Have you had unprotected sex with your boyfriend?”Strategy: Answers are a mix of assessments and implementations. Does thissituation require assessment? Yes. Is there an appropriate assessment?Yes.(1) nurse is interjecting own feelings(2) will require testing, not best response initially(3) implementation, receive HBIG for postexposure prophylaxis; may also receiveHBV vaccine(4) correct–assessment, transmitted through parenteral drug abuse and sexualcontact; determine exposure before implementing

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23. A young adult patient constantly seeks attention from the nurses,stomping away from the nurses’ station and pouting when her requests arerefused. Which of the following responses by the nurse is MOSTappropriate?1. Have the patient establish trust with one staff person with whom therapeuticinterventions should occur.2. Give the patient unsolicited attention when she is not exhibiting the unacceptablebehaviors.3. Ignore the patient when she exhibits attention-seeking behavior.4. Rotate the staff so the patient will learn to relate to more than one nurse.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) staff should use a consistent undivided approach(2) correct–reward nonseeking attention behaviors by giving the patient unsolicitedattention(3) remain nonjudgmental, carry out limit-setting(4) staff should use a consistent undivided approach24. After abdominal surgery, a client has a nasogastric tube attached to lowsuctioning. The client becomes nauseated, and the nurse observes adecrease in the flow of gastric secretions. Which of the following nursinginterventions would be MOST appropriate?1. Irrigate the nasogastric tube with distilled water.2. Aspirate the gastric contents with a syringe.3. Administer an antiemetic medicine.4. Insert a new nasogastric tube.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) tube would be irrigated with normal saline after the position of the tube wasevaluated(2) correct–to confirm placement, nurse should aspirate and test the pH of theaspirate, results should be 0-4(3) does not assess status of nasogastric tube(4) does not assess status of nasogastric tube25. A 38-year-old woman, mother of two, has a mastectomy for breastcancer. When she returns to the physician’s office a month later for aroutine check-up, the nurse asks the client how she has been. Which of thefollowing responses, if made by the client to the nurse, indicates that theclient is experiencing a normal reaction to the surgery?1. “I have been helping my family deal with their feelings about the surgery.”2. “I have been having difficulty coping with the surgery and cry frequently.”3. “I have been unable to leave the house or talk to my friends about the surgery.”4. “I am doing just great since the surgery and have gone back to work at my job.”

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Strategy: Think about each answer choice. Does it describe an expectedresponse to a crisis situation?(1) will not be able to help others this soon after surgery(2) correct–normal reaction one month later(3) excessive, abnormal reaction(4) indicates integration, too early for this stage26. The nurse is caring for clients in outpatient surgery. The mother of afour-year-old asks the nurse how to prepare her daughter for eye surgery.Which of the following statements by the nurse is BEST?1. “Draw a picture of the eye to explain what will happen.”2. “Tell your daughter that the procedure will take one hour.”3. “Use dolls or puppets to explain how to get ready for surgery.”4. “Read an age-appropriate illustrated book about eye surgery to your daughter.”Strategy: Think about growth and development.(1) appropriate for school-aged child(2) preschooler can’t relate to the concept of one hour(3) correct–use puppet or doll to show where procedure is performed; explainprocedure in simpleterms and what the child will see, hear, taste, smell, and feel(4) appropriate for school-aged child27. A 23-year-old woman at 32-weeks gestation is seen in the outpatientclinic. Which of the following findings, if assessed by the nurse, wouldindicate a possible complication?1. The client’s urine test is positive for glucose and acetone.2. The client has 1+ pedal edema in both feet at the end of the day.3. The client complains of an increase in vaginal discharge.4. The client says she feels pressure against her diaphragm when the baby moves.Strategy: Determine how each answer choice relates to pregnancy.(1) correct–abnormal finding, could indicate gestational diabetes (GDM), hazard ofplacental insufficiency(2) not unusual, caused by pressure of enlarging uterus on veins returning bloodfrom lower extremities(3) common near term with increased vascularity of vagina and perineum, onlyabnormal if bloody, foul-smelling, or abnormally colored(4) not unusual, due to pressure of enlarging uterus28. A nurse is caring for a 37-year-old woman with metastatic ovariancancer admitted for nausea and vomiting. The physician orders totalparenteral nutrition (TPN), a nutritional consult, and diet recall. Which ofthe following is the BEST indication that the patient’s nutritional status hasimproved after 4 days?1. The patient eats most of the food served to her.2. The patient has gained 1 pound since admission.3. The patient’s albumin level is 4.0mg/dL.4. The patient’s hemoglobin is 8.5g/dL.

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Strategy: Determine how each answer choice relates to nutritional status.(1) appetite is not the best indicator(2) weight gain may be fluid retention (ascites)(3) correct–albumin levels are best indicators of long-term nutritional status(4) low levels are caused by chemotherapy or cancer, not a good indicator because ittakes a long time to increase levels29. The nurse is caring for clients on a medical/surgical unit and determinesthat several situations need to be addressed. Which of the followingsituations should the nurse attend to FIRST?1. An angry daughter is threatening to sue the hospital because her confused motherfell out of bed during the previous shift.2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteriafor the third time this week.3. The physician calls the unit to ask the nurse to obtain a client’s latest serumelectrolyte results from the lab.4. The husband of a client reports to the nurse that his wife’s nose began bleedingafter she returned from radiation therapy.Strategy: Determine the least stable situation(1) important issue that needs to be addressed after tending to the client who isbleeding(2) patients take priority over personnel issues(3) can be delegated to another staff member(4) correct–should assess client to determine amount and cause of bleeding30. A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which ofthe following nursing actions is the HIGHEST priority?1. Administer oxygen.2. Turn her to the right side.3. Provide adequate hydration.4. Start antibiotics.Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) not a priority(2) not a priority(3) correct–adequate hydration is a priority for any client with sickle cell crisis(4) not a priority31. A client with a peptic ulcer had a partial gastrectomy and vagotomy(Billroth I). In planning the discharge teaching, the client should becautioned by the nurse about which of the following?1. Sit up for at least 30 minutes after eating.2. Avoid fluids between meals.3. Increase the intake of high-carbohydrate foods.4. Avoid eating large meals that are high in simple sugars and liquids.

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Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) client should recline for 30 minutes after eating(2) fluids should be given between meals(3) intake of carbohydrates should be reduced along with highly spiced foods(4) correct–basic guidelines to teach a postgastrectomy client are measures toprevent dumping syndrome, which include: lying down for 30 minutes after meals,drinking fluids between meals, and reducing intake of carbohydrates32. The nurse is assigned to work with the parents of a retarded child.Which of the following should the nurse include in the care plan for theparents?1. Interpret the grieving process for the parents.2. Discuss the reality of institutional placement.3. Assist the parents in making decisions and long-term plans for the child.4. Perform a family assessment to assist in the planning of intervention.Strategy: Answers are a mix of assessments and implementations. Does thissituation require assessment? Yes.(1) inappropriate before the assessment; action can be taken only when thecircumstances are known(2) inappropriate before the assessment; action can be taken only when thecircumstances are known(3) inappropriate before the assessment; action can be taken only when thecircumstances are known(4) correct–assessment, this will help the nurse to know where the family is inregard to grieving, coping, etc.33. The nurse should explain to a client that tolbutamide (Orinase) iseffective for diabetics who1. can no longer produce any insulin.2. produce minimal amounts of insulin.3. are unable to administer their injections.4. have a sustained decreased blood glucose.Strategy: Think about each answer choice.(1) type I insulin-dependent diabetic is unable to produce insulin(2) correct–oral hypoglycemic agents are administered to type II (non-insulin-dependent) clients who are able to produce minimal amounts of insulin(3) type I diabetics who cannot administer their injections need alternate plans to bemade for them to receive the injection from a family member(4) Orinase would be administered for an increase in blood glucose34. A woman at 38-weeks gestation comes to the emergency room withcomplaints of vaginal bleeding. Which of the following statements, if madeby the client, would suggest to the nurse placenta previa as the cause of thebleeding?1. “I feel fine, but the bleeding scares me.”2. “I’ve been more nauseated during the past few weeks.”3. “The bleeding started after I carried four bags of groceries.”4. “I’ve been having severe abdominal cramps.”

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Strategy: All answers are assessments. Think about what each phrase isdescribing and how it relates to a placenta previa.(1) correct–placenta previa is characterized by painless vaginal bleeding(2) nausea not a symptom of placenta previa(3) bleeding is not necessarily related to activity(4) pain not characteristic of placenta previa35. The nurse is caring for an 80-year-old client with Parkinson’s disease.Which of the following nursing goals is MOST realistic and appropriate inplanning care for this client?1. Return the client to usual activities of daily living.2. Maintain optimal function within the client’s limitations.3. Prepare the client for a peaceful and dignified death.4. Arrest progression of the disease process in the client.Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) unrealistic(2) correct–irreversible disease that leads to permanent physical limitations(3) unnecessary, disease usually is not terminal(4) unrealistic, disease is progressive, cannot be arrested36. When using restraints for an agitated/aggressive patient, which of thefollowing statements should NOT influence the nurse’s actions during thisintervention?1. The restraints/seclusion policies set forth by the institution.2. The patient’s competence.3. The patient’s voluntary/involuntary status.4. The patient’s nursing care plan.Strategy: Think about each answer choice.(1) nurse should follow the policies of the institution(2) must get written permission from the patient for restraints; if patient has beenjudged incompetent, permission is obtained from the legal guardian(3) correct–the need for restraints is based on patient’s behavioral status andcondition, not the patient’s voluntary/involuntary status(4) must first try less restrictive means to control patient before using restraints37. A 12-year-old boy injured his right knee yesterday during a soccergame. He is brought to the outpatient clinic by his mother. His right knee ispainful, swollen, and bruised. During the interview, the nurse learns thatthe boy has hemophilia A. Which of the following medications would beBEST for this patient?1. Oxycodone terephthalate (Percodan).2. Ibuprofen (Motrin).3. Enteric-coated aspirin.4. Codeine phosphate (Paveral).

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Strategy: Think about the action of each medication.(1) contains aspirin, contraindicated for persons with bleeding disorders(2) increases bleeding time by decreasing platelet aggregation, contraindicated forpersons withbleeding disorders(3) increases bleeding time by decreasing platelet aggregation, contraindicated forpersons with bleeding disorders(4) correct–analgesic used for moderate to severe pain38. The parents of a one-month-old boy bring their son to the clinic forevaluation of a possible right dislocated hip. If a diagnosis of unilateraldislocation of the right hip is made, which of the following symptoms willthe nurse observe?1. Limited adduction of the right leg.2. Uneven gluteal fold and thigh creases.3. Increase in length of the right limb.4. Internal rotation of the right leg.Strategy: Think about each answer choice.(1) will see limited abduction(2) correct–folds and creases will be longer and deeper on affected side(3) will be decrease in limb length(4) may or may not see internal rotation39. The nurse is administering terbutaline (Brethine) to a client in labor.Prior to administration of the medication, the nurse assesses the client’spulse to be 144. The nurse’s priority action should be to1. withhold the medication.2. decrease the dose by half.3. administer the medication.4. wait 15 minutes, then recheck the rate.Strategy: Answers are a mix of assessments and implementations. Is this asituation that requires validation? No. Determine the outcome of eachanswer choice.(1) correct–maternal tachycardia is a side effect of Brethine; other maternal sideeffects include nervousness, tremors, headache, and possible pulmonary edema;fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferredover ritodrine (Yutopar) because ithas minimal effects on blood pressure(2) should never change a prescribed dosage of medication(3) should not be given with a high pulse rate(4) assessment, maternal tachycardia is a side effect of Brethine; medication shouldbe withheld

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NCLEX Clinical Reasoning and Strategy Exam Preparation 4 With Answers (150 Solved Questions) - Page 16 preview image

40. The nurse is supervising the staff providing care for an 18-month-oldhospitalized with hepatitis A. The nurse determines that the staff’s care isappropriate if which of the following is observed?1. The child is placed in a private room.2. The staff removes a toy from the child’s bed and takes it to the nurse’s station.3. The staff offers the child french fries and a vanilla milkshake for a midafternoonsnack.4. The staff uses standard precautions.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) correct–contact precautions required for diapered or incontinent clients(2) do not remove toys from room, possibly contaminated(3) diet should be high in carbohydrates and protein and low in fat(4) contact precautions required in addition to standard precautions41. The nurse is preparing to administer an injection of haloperidoldecanoate (Haldol D). Which of the following actions by the nurse is MOSTappropriate?1. Massage the injection site.2. Give deep IM in a large muscle mass.3. Use a 2 inch 25 gauge needle.4. Administer the medication in divided doses.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) should not be done because medication is very irritating to subcutaneous tissue(2) correct–medication is very irritating to subcutaneous tissue(3) should use a 2 inch 21 gauge needle(4) should administer in single dose; patient should lie in recumbent position forone-half hour after administration of IM haloperidol decanoate42. The nurse is monitoring a client’s EKG strip and notes coupledpremature ventricular contractions greater than 10 per minute. The nurseshould expect to administer which of the following?1. Atropine sulfate (Atropine) IV.2. Isoproterenol (Isuprel) IV.3. Verapamil (Calan) IV.4. Lidocaine hydrochloride (Xylocaine) IV.Strategy: All answers are implementations. Determine the outcome of eachanswer choice. Is it desired?(1) antiarrhythmic, used for bradycardia(2) antiarrhythmic, used for heart block, ventricular dysrhythmias(3) antihypertensive, calcium-channel blocker(4) correct–Lidocaine is the drug of choice for frequent premature ventricularcontractions (PVC) occurring in excess of 6-10 per minute; for coupled PVCs or for aconsecutive series of PVCs that may result in ventricular tachycardia

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