Download HURST NCLEX Test Taking Strategy -with 100% verified solutions-2024-2025.docx and more Exams Nursing in PDF only on Docsity! Day 4 1 HURST NCLEX Test Taking Strategy -with 100% verified solutions-2024-2025 1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the clientās urine output suddenly increases significantly. Which action takes highest priority? o 1. Monitoring urine output o 2. Checking pulse o 3. Checking blood pressure o 4. Assessing level of consciousness Rationale: 3. Correct: This is the best answer because we are āworriedā this client is going into SHOCK. Soā¦..you better be checking a BP. This is a time where checking the BP is appropriate. If we āassume the worstā I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP. 4. Incorrect: If my client is going into shock the highest priority is to assess the BP. 2. The client is being treated for fluid volume deficit. Which is an expected outcome of successful treatment? o 1. Resolution of orthostatic hypotension o 2. Maintenance of weight loss o 3. Compliance with sodium restricted diet o 4. Maintenance of serum Na above 148 mEq Rationale: 1. Correct: When you are in a fluid volume deficit your blood pressure goes down when you stand up and itās called orthostatic hypotension. Successful treatment would resolve this. 2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my weight should go up. 2 Day 4 3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume Day 4 5 5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal failure. What is the initial client response to this problem? o 1. Respiratory rate increases to blow off acid. o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response. o 3. Kidneys will excrete hydrogen and retain bicarb. o 4. Sodium will shift to cells and buffer the hydrogens. Rationale: 1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe faster to blow off some acid. The respiratory response is fast. 2. Incorrect: No, the clientās respiratory rate is fast, not slow. 3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response. 4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte. 6. The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance is suspected? o 1. Hypercalcemia o 2. Hypokalemia o 3. Hypermagnesemia o 4. Hyponatremia Rationale: 2. Correct: The client has been vomiting so the electrolytes losses are potassium, hydrogen and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is potassium. 1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing 3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related to dysrhythmias. 4. Incorrect: The loss of sodium is related to diarrhea. 6 Day 4 7. The nurse is caring for a client that is drowsy and has an elevated CO2. What are some common drugs that cause retained CO2? Select all that apply ļ£ 1. Narcotics ļ£ 2. Diuretics ļ£ 3. Steroids ļ£ 4. Antiemetics ļ£ 5. Hypnotics Rationale: 1. , 4. & 5. Correct: Yes! ā Narcotics sedate and decrease the respiratory rate. Some antiemetics like promethazine (Phenergan) are very sedating. Hypnotics can cause sedation to point of hypoventilation. 2. Incorrect: No ā Diuretics do not affect breathing patterns. 3. Incorrect: No āSteroids do not affect breathing patterns 8. A client was admitted 24 hours ago with sepsis. Treatment included IV therapy of lactated Ringers (LR) at 150 ml/hr, broad spectrum antibiotics, and steroid therapy. How will the nurse know that treatment has been successful? Select all that apply. ļ£ 1. Blood pressure 96/68; HR- 98; RR- 20 ļ£ 2. Serum Glucose- 110 ļ£ 3. Hgb- 12; Hct- 38 ļ£ 4. pH- 7.30; pCO2- 48; HCO3- 24 ļ£ 5. Urinary output at 25 ml/hr ļ£ 6. Awake, alert to person, place and time Rationale: 1., 2., 3. & 6. Correct: The systolic BP should be greater than 90. The other lab work is normal as well. 4. Incorrect: The client is still in respiratory acidosis, so is not better. 5. Incorrect: Urinary output should be at least 30 ml/hr. Day 4 7 9. The daytime charge nurse identifies that a client was treated for what condition during the night after reading the following chart entries? o 1. Respiratory Alkalosis o 2. Respiratory Acidosis o 3. Metabolic Alkalosis o 4. Metabolic Acidosis Rationale: 2. Correct: Look at pH? Acid and which other lab says acidā¦.CO2. Is CO2 a respiratory or metabolic chemical? Respiratory. So the condition is Respiratory Acidosis. 1. Incorrect: Not alkalotic condition, the pH is acid. 3. Incorrect: Not metabolic condition, because HCO3 is normal. 4. Incorrect: Not metabolic condition, because HCO3 is normal. Progress Notes: 11/22/10- 0125 Restless, picking at sheets and pulling at IV tubing. Disoriented to place and time. Dyspnea on exertion noted. Dr. Timmons notified. Stat ABGs ordered.------- Mary Minee, RN 11/22/10- 0145 Oxygen started at 2 liters per nasal cannula. Incentive Spirometry and deep breathing exercises initiated. Head of bed elevated to 30 degreesMary Minee, RN Lab reports: pH- 7.30 pO2- 91mmHg pCO2- 50 mmHg HCO3- 24 mEq/L 10 Day 4 12. A client weighing 154 pounds is admitted to the burn unit with second and third degree burns covering 40% total body surface area. Normal Saline IV fluid resuscitation is ordered at 4 ml/kg per percentage of total body surface area burned over the first 24 hours. How much fluid does the nurse calculate the client will receive in 24 hours? Provide your answer in whole numbers ml Rationale: Correct: 11,200 ml in the first 24 hours 154 pounds/ 2.2 kg= 70 kg 4 ml x 70 kg= 280 280 ml x 40 tbsa= 11,200 ml in the first 24 hours 13. A client five days post electrical burn states, āI am feeling fine and would like to go home.ā What is the rationale for this length of stay? o 1. Bone damage always occurs resulting in pathologic fractures. o 2. Vascular and nerve damage may cause organ failure. o 3. Continuous EKG monitoring is always required. o 4. Infection is sometimes a delayed response. Rationale: 2. Correct: The current of electrical burns damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, and we worry about organ failure. 1. Incorrect: Bones are dense and not really affected by electrical current. 3. Incorrect: Cardiac monitoring is for the first 48 hours, not the reason for a prolonged stay. 4. Incorrect: Infection is not a priority in an electrical burn. Day 4 11 14. A client is hospitalized hundreds of miles from home for a bone marrow transplant. The client is in reverse isolation while undergoing total body irradiation and intense chemotherapy. The clientās sibling, who has driven a great distance, comes to visit and has obvious manifestations of an upper respiratory infection. Which nursing action would be most appropriate at this time? o 1. Do not allow the sibling to visit, and do not upset the client by mentioning the siblingās visit. o 2. Allow the sibling to wave at the client through the window or door, then offer the use of the unit phone so they can talk. o 3. Allow the sibling to visit donning a sterile gown, mask, and gloves, but prohibit physical contact. o 4. Allow the sibling to visit after donning a sterile gown, mask, and gloves and have the client wear a mask. Rationale: 2. Correct: This is the only safe answer for the client. 1. Incorrect: No, allow client to see from distance and talk with client. 3. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing. 4. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing. 15. A client is admitted to the Emergency Department with burns to the chest and legs. Which assessment is the highest priority? o 1. Calculating the āRule of Ninesā o 2. Determining the time of the burn o 3. Ascertaining if the burn occurred in an enclosed area o 4. Calculating the Parkland formula Rationale: 3. Correct: A fire in an enclosed area brings on the concern for carbon monoxide poisoning. In addition with the burns to the chest there is the added potential for airway damage. 1. Incorrect: Important for surface area estimate but not airway. 2. Incorrect: Important for fluid replacement but not #1. 4. Incorrect: Determines the amount of fluid to be replaced, but not airway! 12 Day 4 16. The client has returned to your unit after an escharotomy of the forearm. What is the priority nursing assessment? o 1. Infection o 2. Incision o 3. Pain o 4. Tissue perfusion Rationale: 4. Correct: Yes! They do the escharotomy for circulation problems, check circulation! 1. Incorrect: Not right away! 2. Incorrect: No, that incision is going to be bad and ugly. 3. Incorrect: Well this is the second best answer ā the escharotomy for the lack of circulation and pain is one indicator of adequate circulation, so go with the real thing first. 17. A client had surgery for cancer of the colon and a colostomy was performed. Prior to discharge, the client states that he will no longer be able to swim. The nurseās response would be based on which understanding? o 1. Swimming is not recommend, the client should begin looking for other areas of interest. o 2. Swimming is not restricted if the client wears a dressing over the stoma at all times. o 3. The client cannot go into water that is over the stoma area, he can only go into water up to the stoma area. o 4. There are no restrictions on the activity of a client with a colostomy; all previous activities may be resumed. Rationale: 4. Correct: With the colostomy bag providing an airtight seal they can take a shower, bath, and go swimming. 1. Incorrect: Swimming is allowed with the airtight seal that the colostomy bag provides. 2. Incorrect: Client will wear colostomy bag with airtight seal not a dressing over the stoma. 3. Incorrect: No, the client can swim with the airtight seal colostomy bag. Day 4 15 3. Incorrect: This is a manifestation of hypothyroidism. 6. Incorrect: This is a manifestation of hypothyroidism. 22. A nurse caring for a cancer client is teaching the client about precautions concerning the clientās risk for bleeding problems. The nurse identifies that teaching has been successful regarding bleeding precautions when the client makes which statement? Select all that apply. ļ£ 1. āI cannot shave while I am at risk for bleeding.ā ļ£ 2. āIt is important to gargle with a commercial mouthwash three times a day.ā ļ£ 3. āStool softeners will help prevent rectal bleeding.ā ļ£ 4. āPrior to sexual intercourse, I will use a water-based lubricant.ā ļ£ 5. āI will use a soft toothbrush.ā Rationale: 3., 4. & 5. Correct: Stool softeners prevent constipation and straining that may injure rectal tissue. Water-based lubricant will prevent friction and tissue trauma. Soft toothbrush will prevent trauma to gum tissue. 1. Incorrect: The client can shave with an electric razor. An electric razor will prevent trauma. 2. Incorrect: Commercial mouthwash should be avoided as they contain high alcohol content that will dry oral tissues and lead to bleeding. 23. The nurse is caring for a client that is paranoid in the locked psychiatric unit. It is time for the clientās individual session, but the client is very agitated with outburst of shouting. What would be the nurseās best action at this time? o 1. Have the client sit with you and say a prayer. o 2. Explain that shouting is not allowed and send them to group session. o 3. Redirect the client to another activity. o 4. Call for assistance and put the client in seclusion. Rationale: 3. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now. 1. Incorrect: They are agitated, shoutingā¦Now you think it is reasonable to get them to sit and pray? Nope! 2. Incorrect: Setting limits is good, but here the client is disruptive. 4. Incorrect: Oh boy ā itās going to be a fight! NO! Thatās not nice. 16 Day 4 24. Which dietary consideration is the most important for the nurse to teach to a client with hypothyroidism? o 1. Increase carbohydrate intake. o 2. Increase fluid intake. o 3. Avoid shellfish. o 4. Increase fiber. Rationale: 4. Correct: YES! Low thyroid clients have constipation, so increased fiber. 1. Incorrect: No they need less calories, not more. Their metabolism is slowed. 2. Incorrect: What does increasing fluid have to do with it? Nothing 3. Incorrect: What does avoiding shellfish have to do with it? Nothingā¦thatās if they are allergic to iodine. 25. Following a thyroidectomy a client is complaining of shortness of breath and neck pressure. What should the nurse do? o 1. Stay with the client, remove the dressing, and elevate the head of bed. o 2. Call a code, open the trach set and position the client flat supine. o 3. Have the client say āEEEā to check for laryngeal integrity and assess Chvostekās sign. o 4. Call the doctor and assess vital signs. Rationale: 1. Correct: Yes! Sounds like respiratory distress, Looks like respiratory distress, get that dressing off the neck and see if they can breathe any better. 2. Incorrect: Not yet! Do something first to see if it gets better. 3. Incorrect: Well just look and check and look and check ā do something. 4. Incorrect: Donāt leave the client. Day 4 17 26. A client is admitted for evaluation of cardiac arrhythmias. What would be the most important information to obtain when assessing this client? ļ£ 1. Ability to perform isometric exercises as ordered. ļ£ 2. Changes in level of consciousness or behavior. ļ£ 3. Recent blood sugar changes. ļ£ 4. Compliance with dietary fat restrictions. Rationale: 2. Correct: The only answer that deals with cardiac output is #2. When the cardiac output drops, then the LOC will decrease. 1. Incorrect: What do isometrics have to do with cardiac output? 3. Incorrect: What does blood sugar have to do with cardiac output? 4. Incorrect: Arrhythmias have nothing to do with fat. 27. The nurse is caring for a client with deep vein thrombosis of the left leg. Which nursing goal would be most appropriate for this client? ļ£ 1. To decrease inflammatory response in the affected extremity. ļ£ 2. To increase peripheral circulation. ļ£ 3. To prepare client and family for anticipated vascular surgery. ļ£ 4. To prevent hypoxia associated with the development of pulmonary emboli. Rationale: 1. Correct: When blood sets in one area it inflames the area, and a clot can form. 2. Incorrect: You do not need oxygen when you have a venous problem. The only time you need oxygen is when you have an arterial problem. 3. Incorrect: Getting ahead of yourself. 4. Incorrect: Getting ahead of yourself. 20 Day 4 32. In planning a menu for a client suffering from an acute manic episode, which meal would the nurse determine to be most appropriate? o 1. Spaghetti and meat balls, salad, banana o 2. Beef and vegetable stew, bread, vanilla pudding o 3. Fried chicken leg, ear of corn, apple o 4. Fish fillets, stewed tomatoes, cake Rationale: 3. Correct: Something they can hold in their hand and it is high calorie. 1. Incorrect: Spaghetti is too frustrating for anyoneā¦.Never give a manic client something frustrating to eat. 2. Incorrect: Itās hard to walk around and eat beef stew. 4. Incorrect: Itās hard to walk around and eat stewed tomatoes. 33. The manic client has just interrupted the counselorās group session for the 4th time and states āI already know this information dealing with others when you are down.ā What should the nurse do at this time? o 1. Engage the client to walk with you to make another pot of coffee. o 2. Ask the client to reflect on the clientās behavior to determine if it is appropriate. o 3. Ask the group to tell the client how they feel when she interrupts. o 4. Instruct the client to perform jumping jacks and counting aloud to get rid of some energy. Rationale: 1. Correct: Yes! Get them away and doing something purposeful. 2. Incorrect: That is embarrassing and humiliating to the client. 3. Incorrect: Sometimes this will be helpful during times of therapy ā but the client is manic at this time, will she even believe them? 4. Incorrect: No, this is getting her active, but can the group continue with this attention seeking jumping, counting person? No. Get her away from the activity. Day 4 21 34. After examining the eyes of the following client, the nurse would expect which correlating lab work? o 1. Elevated cortisol level o 2. Elevated thyroxine levels o 3. Decreased parathormone levels o 4. Increased calcitonin level Rationale: 2. Correct: Exophthalmos is a classic finding in Gravesā disease. It is a protrusion of the eyeballs from the orbits due to impaired venous drainage from the orbit, which causes increased fat deposits and edema in the retro-orbital tissues. To diagnose hyperthyroid or Graveās Disease you do a thyroxine level which when elevated indicates a hyperthyroid state. 1. Incorrect: This would indicate hyperfunctioning of the adrenal gland as in Cushing ās syndrome. 3. Incorrect: This lab would indicate hypoparathyroidism. 4. Incorrect: Again, this level would tell you about the parathyroid. 35. A client with schizophrenic disorder begins to talk about fantasy material. What would be the most appropriate nursing action? o 1. Encourage the client to focus on reality-based issues. o 2. Allow the client to continue to talk so as not to interrupt the delusion. o 3. Ask the client to explain the meaning behind what he is saying. o 4. Persuade the client that his thoughts are not true. Rationale: 1. Correct: Get them out of the delusion to get into the real world. 2. Incorrect: Never allow clients to continue on in a delusionā¦.this is reinforcing it. 3. Incorrect: Reinforcing the delusion. 4. Incorrect: Waste of timeā¦.produces anxiety. 22 Day 4 36. A client has been admitted to the medical unit with hepatitis B. Identify what quadrant the nurse would assess for hepatomegaly. Place an āxā in the correct location. Rationale: Correct: The liver is located under the right lower rib cage. The liver may be palpable in the right upper quadrant. 37. Which client is at highest risk for suicide? o 1. Seventy-six year old widower with chronic renal failure o 2. Nineteen year old taking antidepressants o 3. Twenty-eight year old post-partum crying weekly o 4. Fifty year old with obsessive-compulsive disorder (OCD) Rationale: 1. Correct: Yes- elderly with chronic disease, especially men, are very high risk. 2. Incorrect: There is an increased incidence and risk in this population-but look for the highest risk. 3. Incorrect: Many post-partum clients cry weekly, this is not the red flag client. 4. Incorrect: Chronic disease, but the widower wins out as the higher risk. Day 4 25 42. A newly diagnosed diabetic client is demonstrating to the nurse how to draw up regular insulin 15 units and NPH insulin 10 units into the same syringe. The nurse knows that the client successfully demonstrates this procedure if done in what order? Place in the correct order. All options must be used. Rationale: 4., 7., 2., 1., 6., 5. & 3. Correct: This is the correct procedure. 43. What must the nurse do while caring for a client with an eating disorder? o 1. Encourage client to cook for others. o 2. Weight the client daily and keep a journal. o 3. Restrict access to mirrors. o 4. Monitor food intake and behavior for one hour after meals. Rationale: 4. Correct: Yes! This is the primary problem and the most life threatening. 1. Incorrect: No ā remember the focus is on control and attention to food ā they need to eat. 2. Incorrect: No ā we donāt let them know their weight, if they gain one ounce, they will try anything to lose it! 3. Incorrect: They still have to brush their hair and put on make-up ā itās the eating we just focus on to keep them alive. 1. Inject 15 units of air into regular insulin bottle. 2. Inject 10 units of air into NPH insulin bottle. 3. Prepare skin site and inject insulin. 4. Roll insulin bottles between hands. 5. Draw up 10 units of NPH insulin into the insulin syringe. 6. Draw up 15 units of regular insulin into insulin syringe. 7. Wipe the top of insulin bottles. 26 Day 4 44. Which condition would warrant the nurse discontinuing the intravenous infusion of oxytocin (Pitocin)? o 1. Fetal heart rate baseline of 140-160 bpm o 2. Contractions every 1-1/2 minutes lasting 70-80 seconds o 3. Maternal temperature of 101.2 degrees o 4. Early decelerations in the fetal heart rate Rationale: 2. Correct: These contractions are too long and too often. 1. Incorrect: That heart rate is fine. 3. Incorrect: Temperature has nothing to do with Pitocin (uterine contractions). 4. Incorrect: Early decels are no big deal. 45. In preparing care for a client with Parkinsonās disease, which nursing diagnoses should the nurse include? Select all that apply. ļ£ 1. Impaired physical mobility related to muscle rigidity ļ£ 2. Imbalanced nutrition, greater than body requirements related to limited exercise ļ£ 3. Self-care deficits related to motor disturbance ļ£ 4. Impaired verbal communication related to inability to move facial muscles ļ£ 5. Unilateral neglect related to muscle paralysis. Rationale: 1. , 3. & 4. Correct: These are appropriate nursing diagnoses for a client with Parkinsonās disease. 2. Incorrect: The client is more likely to have imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing. Day 4 27 46. The client is transferred to the Neuro Unit after developing right sided paralysis and aphasia. Which nursing action should be included in the nursing care plan in order to promote communication with the client? o 1. Encourage client to shake head in response to questions. o 2. Speak in a loud voice during interactions. o 3. Speak using phrases and short sentences. o 4. Encourage the use of radio to stimulate the client. Rationale: 3. Correct: Client is having trouble communicating. Get simple. Promote communication. 1. Incorrect: Never pick an answer that doesnāt allow the client to speak. They havenāt told us what kind of aphasia. They could have expressive aphasia. 2. Incorrect: Donāt yell at the client. 4. Incorrect: Use of radio will not promote communication with the client. Radio should be turned off when communicating with client to decrease distraction. 47. The client delivered a 9-pound 12-ounce baby 1 hour ago. You note during her 15-minute assessment that she saturated 2 pads and that she is lying in a small puddle of blood. Which nursing action should take priority? o 1. Call for assistance. o 2. Massage the fundus if boggy. o 3. Assess vital signs. o 4. Assess the perineum for tears. Rationale: 2. Correct: This is the only answer that will STOP BLEEDING!!!! 1. Incorrect: Call for assistanceā¦doesnāt stop the bleedingā¦since it says priority you have to sayā¦.if I could only do ONE thingā¦if you choose this answer you get assistance in the room, but you have not STOPPED THE BLEEDING. 3. Incorrect: This is good, but how will it stop the bleeding. 4. Incorrect: The perineum is not whatās hemorrhaging. 30 Day 4 52. After administration of epidural anesthesia, the laboring clientās blood pressure drops to 92/42. What would be the priority nursing intervention? o 1. Elevate the head of the bed. o 2. Begin oxygen by face mask at 40%. o 3. Change her position to side-lying. o 4. Begin dopamine as ordered. Rationale: 3. Correct: When you turn them on their side this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O2 doesnāt bring up the BP. 4. Incorrect: Stay away from drugs as long as you canā¦..Besides this says a NURSING ACTION. 53. The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with flail chest? o 1. Biotās breathing o 2. Sucking sounds with respirations o 3. Paradoxical chest wall movement o 4. Hypotension and bradycardia Rationale: 3. Correct: Hallmark of flail chest! 1. Incorrect: No, but itās associated with neurological problems. 2. Incorrect: Open chest wounds suck not closed chest wounds. 4. Incorrect: Well, the hypoxia and trauma will lead to hypotension and tachycardia, not bradycardia. Day 4 31 54. The nurse is caring for a client 28 weeks pregnant that complains of swollen hands and feet. Which symptom below would cause the most concern? o 1. Nasal congestion o 2. Hiccoughs o 3. Capillary blood glucose of 150 o 4. Muscle spasms Rationale: 4. The muscle spasms ā watch for seizure. 1. No, they always have a stuffy nose. 2. Hiccoughs would be second best answer indicating nerve/muscle irritation. 3. Is this right after dairy queen? 55. The nurse is writing a care plan for a client admitted following chest tube placement for a spontaneous pneumothorax. Which intervention would be appropriate for the nurse to include? o 1. Keep the water seal chamber at the level of the right atrium. o 2. Tape all connections between the chest tube and drainage system. o 3. Notify the physician if there is continuous bubbling in the suction control chamber. o 4. Empty the collection chamber and record the amount of drainage every shift. Rationale: 2. Correct: Tape all connections. 1. Incorrect: Must be kept below the chest. 3. Incorrect: If itās hooked to suction itās suppose to bubble. 4. Incorrect: Empty every shift? Donāt empty them, you change them out when they get full. 32 Day 4 56. A child with a radial fracture complains of itching to the casted area. What is the appropriate nursing action to relieve itching? o 1. Allow the child to use a Q-tip to scratch the area. o 2. Visualize the toes and area above the cast to identify areas of irritation. o 3. Apply an ice pack for 10-15 minutes. o 4. Explain to the child that itching is an indication the fracture is healing. Rationale: 3. Correct: This will change the sensationā¦..Normally the answer is use a cool blow dryer, but they wanted to see if you would be flexible with what you know. Use an ice pack that will not get the cast wet. 1. Incorrect: A Q-tip is soft, trying to make you feel like this is okay to put into a cast. 2. Incorrect: How does visualizing toes decrease itchingā¦.it doesnāt. 4. Incorrect: How does explaining the Pathophysiology help decrease itching? It doesnāt. 57. Following a hip replacement surgery, an elderly client is ordered to begin ambulation with a walker. In planning nursing care, which statement by the nurse will best help this client? o 1. Sit in a low chair for ease in getting up in a walker o 2. Make sure rubber caps are present on all 4 legs of the walker o 3. Begin weight-bearing on the affected hip immediately. o 4. Practice tying your shoes before using the walker Rationale: 2. Correct: Rubber caps on all 4 legs of walker will prevent falls. 1. Incorrect: If the client sits in a low chair, their hip may dislocate. You prevent hip flexion greater than 90 degrees and leg adduction. Both can cause dislocation. 3. Incorrect: We do not begin weight bearing immediately but as soon as the physician says. 4. Incorrect: If you bend over to tie your shoes, what is your hip going to do- dislocate. You prevent hip flexion greater than 90 degrees and leg adduction. Both can cause dislocation. Day 4 35 62. What is the diet of choice for a client on hemodialysis? o 1. Extra protein, low sodium, fluid restriction o 2. Fluid restriction, low sodium, low protein o 3. Low sodium, low potassium, low carbohydrates o 4. Extra carbohydrates, low fat, low sodium Rationale: 2. Correct: Yes, we need low protein diet to restrict the waste build up. The client will get dialyzed every other day so restrict the fluid, and restrict the sodium to stop the thirst and fluid excess. 1. Incorrect: Not extra protein. 3. Incorrect: Low carbohydrates 4. Incorrect: Doesnāt restrict either protein or fluid 63. In order to maintain asepsis, what should the client on home peritoneal dialysis be taught? o 1. Drink only distilled water o 2. Cap Tenckhoff catheter when not in use o 3. Boil the dialysate one hour. o 4. Clean the arteriovenous fistula with hydrogen peroxide daily Rationale: 2. Correct: Capping the Tenckhoff catheter prevents dialysate leakage and bacterial invasion. 1. Incorrect: What does drinking distilled water have to do with it? Nothing 3. Incorrect: They thought they would throw this one in there, maybe they could get you into boiling that dialysate, and burn out the peritoneum so we donāt have to worry about this anymore we can go straight to hemo now. 4. Incorrect: Do you have an arteriovenous fistula? Not with peritoneal dialysis. That goes with hemodialysis. 36 Day 4 64. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The clientās spouse asks the nurse about the reason for having two chest tubes. The nurseās response is based on the knowledge that the lower chest tube is placed to: o 1. Remove air form the pleural space. o 2. Create access for irrigating the chest cavity. o 3. Evacuate secretions from the bronchioles and alveoli. o 4. Drain blood and fluid from the pleural space. Rationale: 4. Correct: Fluid will drain down and the lower chest tube is for drainage of blood and fluid from pleural space. 1. Incorrect: The top chest tube will remove air from pleural space. 2. Incorrect: No, a nurse will not irrigate the chest cavity. 3. Incorrect: No, chest tube is in pleural space. 65. The nurse is caring for a female that is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do? o 1. Allow the client to discuss her fears and encourage her to talk with her physician. o 2. Tell her the good things that she will able to do without more children. o 3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time. o 4. Advise the client to put off having the surgery until she is sure. Rationale: 1. Correct: This may be anticipatory grieving and being scared. Let the person talk and encourage them to talk again to the physician. They need reassurance that they are making the right decision. 2. Incorrect: This is not her fear and not helpful in this situation. 3. Incorrect: Not an appropriate answer and we donāt freeze ovaries. 4. Incorrect: The cancer is already advanced stages, will the waiting help her survive? Day 4 37 66. You are assisting a burn client at the scene of the fire. Which intervention will prevent infection? o 1. Do nothing until the client arrives in Emergency Department. o 2. Cleanse the burn with betadine. o 3. Apply antibiotic ointment and wrap with a kerlix. o 4. Remove non adherent clothing and wrap in a clean sheet or clothing. Rationale: 4. Correct: Yes, this can be done at the scene. 1. Incorrect: No, doing nothing is not the right action. 2. Incorrect: At the scene betadine is not available. 3. Incorrect: At the scene antibiotic ointment and kerlix is not available.