Nclex Cris 2-50 Questions with 100% Correct Answers | Verified | Latest Update, Exams of Advanced Education

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Nclex Cris 2- 50 Questions with 100%

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Theinurseisupervisesitheitransferiofianielderlyiclientiwithileft- sidediweaknessifromitheibeditoitheichair.iAfteriassistingitheiclientitoiaisi ttingiposition,iwhichiofitheifollowingiactionsishoulditheinurseitakeiNEXT ? i1.iPlaceinonskidishoesionitheiclient'sifeet. i2.iInstructitheiclientithatisheiwillibeimovingitowardiherileftiside. i3.iAskitheiclientitoipivotioniherirightifoot. i4.iSupportitheileftilegiwithitheinurse'siknee.i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer. 1)iCORRECT — iinstructiclientitoiwearishoesiwhenitransferring,inonskidisolesidecreaseit heichanceiofifalls 2)iificlientihasiweakeriside,itransferitowarditheistrongeriside;inurseishou ldiassessiifiaitransferibeltiisirequired;iplaceichairiati 4 5°iangleitoitheibed 3)iappropriateiaction;ifirstiputishoesioniclient;iinstructiclientitoiuseiarmr estsionichairiforisupport

4)iappropriateiactionitoiprovideistabilityitoiweakilegisoithaticlienticanist andiduringitransfer Ai 16 - year- oldigirliisibroughtitoitheiemergencyiroomibyiheriparentsiforievaluationio fianieatingidisorder.iWhenitheinurseiapproachesitheiclientitoidrawiaiblo odisample,itheiclienticriesiout,i"Iihateihavingimyibloodidrawn.iGoiaway! "iWhichiofitheifollowingiresponsesibyitheinurseiisiBEST? i1.i"What'sitheimatter?iAreiyouiafraidiofiwhatiweiareigoingitoifind?" i2.i"Whatiisiitiaboutihavingiyouribloodidrawnithatiupsetsiyou?" i3.i"Takeiaideepibreath.iItiwillibeioveribeforeiyouiknowiit." i4.i"I'llibeibackiini 15 iminutesisoiweicanidiscussiyouriconcern."i- iCorrectiAnswer- Strategy:i"BEST"iindicatesidiscriminationiisirequireditoiansweritheiques tion. 1)iyes/noiquestion;inurseiisimakingianiassumption 2)iCORRECT — iopen- ended;irelatesitoiclient'siverbaliandinonverbalicommunicationiandiresp ondsitoitheiclient'sifeelings 3)i"don'tiworry"iresponse;inontherapeutic

4)idoinotileaveitheiclientialone Theinurseicaresiforiclientsiinitheiprenataliclinic.iAiclienticomesitoitheiclin iciforiaiprenatalivisitioniJunei6.iHerilastimenstrualiperiodiwasiDecemberi 10.iTheinurseiexpectsitheiclient'sifundaliheightitoimeasure i1.i 24 icm. i2.i 26 icm. i3.i 28 icm. i4.i 30 icm.i-iCorrectiAnswer-Strategy:iThinkiaboutieachianswer. 1)iincorrect,idetermineiEDCibasedioniNiäigele'sirule- dateiLMPiDec.i10;iEDB-Sept.i17;iclientiisi 26 iweeksipregnant;ifromi 24 - 34 iweeks,ifundaliheighticorrelatesiwelliwithiweeksiofigestation;i 24 icmiisi approximatelyi 24 iweeks'igestation 2)iCORRECT — iclientiisi 26 iweeksipregnant;ifundaliheightishouldicorrelateiwithiweeksio fipregnancy 3)ifundusiisitooihigh 4)ifundusiisitooihigh

Recentlyiseveralistaffimembersionitheiunitihaveicomplainediofibackistra in.iTheinurseideterminesithatitheistaffiisinoticonsistentlyiusingicorrectib odyimechanicsiwhenitransferringipatients.iWhichiofitheifollowingisugge stionsishoulditheinurseimakeiFIRST? i1.i"Encourageiyouripatientsitoiassistiasimuchiasipossible." i2.i"Useiyouriarmsiandilegsiwhenimovingiaiclient." i3.i"Determineiifihelpiisirequireditoitransferiaipatient." i4.i"Positioniyourselficloseitoitheipatient."i-iCorrectiAnswer- Strategy:iAssessibeforeiimplementing. 1)idecreasesitheinurse'siworkloadiandipromotesiclientistrengthiandiinde pendence 2)iappropriateiaction;iuseitheilargerimusclesiofitheibodyiandinotitheibac k;idon'titwistispine 3)iCORRECT — ifirstistepiisitoiassess;idetermineitheiweightitoibeitransferrediandiifihelpi( otheristaffimembers,imechanicalidevices)iisirequirediandiavailable 4)iminimizesitheiforceifeltibyitheinurse;ialwaysikeepiweightitoibeiliftedicl oseitoitheibody

Aiclientiisireceivingipackediredibloodicells.iSeveraliminutesiafteritheiinfu sioniisistarted,itheiclienticomplainsiofinauseaiandilowibackipain.iItiisiMO STiimportantiforitheinurseitoitakeiwhichiofitheifollowingiactions? i1.iObtainiaiurineispecimen. i2.iStartianiIViofiDi 5 iW. i3.iDiscarditheibloodicontaineriiniaibiohazardicontainer. i4.iDecreaseitheirateiofitheitransfusion.i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)iCORRECT — ishouldibeisentitoilabiforihemoglobinidetermination;isymptomsiofihemo lyticireactioniincludeinausea,ivomiting,ipainiiniloweriback,ihypotension,i increaseiinipulseirate,idecreaseiiniurinaryioutput,ihematuria 2)ishouldirestartinormalisaline;istopitheiblood,isupportiveicare:ioxygen,i Benadryl,iairwayimanagement 3)icontainerishouldibeireturneditoilab 4)ishouldibeidiscontinuedidueitoihemolyticireaction;idrawibloodisamplei foriplasma,ihemoglobiniculture,iandiretyping Ai 75 - year- oldiclientiisibroughtibyihisiwifeitoitheioutpatienticlinic.iTheinurseinotesit

hatitheiclientihasiai 10 - yearihistoryiofichronicirenalifailureiandihasibeenitakingicimetidinei(Taga met)iforitwoiweeks.iItiisiMOSTiimportantiforitheinurseitoiinvestigateiwhi chiofitheifollowingistatementsimadeibyitheiclient'siwife? i1.iMyihusbandihasibeenicomplainingithatihisibowelimovementsiareihar ditoipass. i2.iMyihusbanditakesihisiTagametijustibeforeiheieatsihisimeals. i3.iMyihusbandiseemsitoibeihavingimoreitroubleiwithihisimemoryilately. i4.iMyihusbandisometimesihasiaiheadacheiafterireadingitheinewspaper.i

• iCorrectiAnswer- Strategy:i"MOSTiimportantitoiinvestigate"iindicatesianiadverseireaction . 1)iTagametidecreasesigastricisecretionibyiinhibitingitheiactionsiofihista mineiatitheiHi 2 i- receptorisite;iconstipationiisiaicommonisideieffectiofithisimedication;ish ouldiincreaseifiberiinidiet;inotimostiimportant 2)iTagametishouldibeitakeniwithimealsiandiatibedtime 3)iCORRECT — ielderlyiclientsiandiclientsiwithirenaliproblemsiareimostisusceptibleitoiC NSisideieffectsi(confusion,idizziness)iofitheimedication;idosageimayinee ditoibeireduced

4)iheadacheimayibeisideieffectiofimedication,iorimayibeicausedibyineedi toichangeiglasses;inotimostiimportant Theinurseicaresiforianiolderiwomaniwithifrequentibladderiincontinencei followingiaicerebrovasculariaccidenti(CVA).iWhichiofitheifollowingiactio nsibyitheinurseiisiMOSTiappropriate? i1.iPerformiintermittenticatheterizationsiusingisterileitechnique i2.iTeachitheipatientihowitoiperformiValsalvaimaneuver. i3.iInstructitheipatientihowitoiperformitheiCrediéimaneuver. i4.iToiletitheipatientiwhenisheiawakensiinitheimorningiandibeforeiandiaf terimeals.i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer. 1)ionlyiusediforiproblemsiwithiretention 2)istrainingiandibearingidownionitheiabdominalimusclesialtersitheihearti rate;iwillinotipreventiincontinence 3)iuseditoiinitiateiurinationiwhenithereiisiretention;iplaceiaicuppedihand ioveritheibladderiandipushiinwardiandidownward 4)iCORRECT — iwilliestablishiairegularitoiletingiroutine

Aniolderimaniisireturneditoihisihospitaliroomithreeihoursiafteriaitransur ethraliresectioniofitheiprostatei(TURP).iTheipatientihasiaicontinuousibla dderiirrigationi(CBI).iWhichiofitheifollowingiobservations,iifimadeibyithei nurse,irequiresianiintervention? i1.iTheipatientiisiinibediwithihisilegsidrawniupitoihisiabdomen. i2.iThereiisi 500 iccifluidiinitheiurinaryidrainageibag. i3.iThereiisi 350 icciofireddishiurineiinitheidrainageibag. i4.iTheiheadiofitheipatient'sibediisielevatedi 45 idegrees.i-iCorrectiAnswer- Strategy:i"Requiresianiintervention"iindicatesiaipotentialicomplication. 1)iCORRECT — iindicatesipain;ialso,icatheteriisitapeditoithigh,iandilegishouldibeikeptistr aightitoimaintainitractionionitheicatheter 2)iexpectedidueitoitheiCBI;iassessiforishockiandihemorrhage;icheckidres singiandidrainage;iurineimayibeibrightiredifori 12 ih;imonitorivitalisigns 3)iexpectedidrainageisooniafterisurgery;iCBIicontainsiisotonicifluidiusedi toikeepitheicatheteripatent 4)inoirestrictionionipositioningiasilongiasilegithatihasicatheteritapeditoiiti isistraight

Theinurseionitheimedical/surgicalifloorireceivesifourinewiadmissions.iW hichiofitheifollowingiclientsishouldibeiplacediiniaiprivateiroom? i1.iAiclientiwithiaidrainingiabdominaliabscessicoverediwithiaidressing. i2.iAiclientidiagnosediwithiinfluenza. i3.iAiclientidiagnosediwithicanceriwhoiappearsiseptic. i4.iAiclientiwithidiverticulitisicomplainingiofiabdominalipain.i- iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)istandardiprecautionsirequirediasilongiasitheiabscessiisicoverediwithiai dressingianditheidressingicontainsitheidrainage 2)iCORRECT — irequiresidropletiprecautions;iplaceiiniprivateiroomioriwithipatientsiwit hitheisameiinfection;imaintainispatialiseparationiofiatileasti 3 ifeet;idooric aniremainiopen 3)imicroorganismsihaveientereditheibloodstreamidueitoiimpairediimmu neifunction;istandardiprecautions;iassessiforis/sishock 4)istandardiprecautions

Theinurseiperformsiaiprenataliassessmentioniaiclientiati 20 iweeks'igestat ion.iIdentifyitheilocationiwhereitheinurseiexpectsitoipalpateitheiclient'sif undus.i-iCorrectiAnswer-Strategy:iRecallitheifundaliheightiati 20 iweeks. Theicorrectianswer:iatitheileveliofitheiumbilicus. 10 itoi 12 iweeksi — ifundusislightlyiaboveisymphysisipubis 16 iweeksi — ifundusihalfwayibetweenisymphysisipubisiandiumbilicus 20 itoi 22 iweeksi — ifundusiatitheileveliofitheiumbilicus 28 iweeksi — ifundusithreeifingerbreadthsiaboveitheiumbilicus 36 iweeksi — ifundusijustibelowiensiformicartilage Theihomeicareinurseivisitsiaiclientidiagnosediwithiprogressiveisystemicis clerosis.iTheiclienticomplainsithatisheiisihavingimoreitroubleiswallowing iandimovingiherirightihand.iWhichiofitheifollowingiresponsesibyitheinurs eiisiMOSTiimportant? i1.i"Thisimustibeiaidifficultitimeiforiyou." i2.i"Youishouldischeduleianiappointmentiwithiyourihealthicareiprovider. "

i3.i"Caniyouitolerateipressureioniyourihand?" i4.i"Tellimeimoreiaboutitheiproblemsiyouiareihavingiswallowing."i- iCorrectiAnswer-Strategy:i"MOSTiimportant"iindicatesipriority. 1)iitiisiimportantitoiallowiclientitoiverbalizeifeelings,ibutiphysicalineedsit akeipriority 2)imayibeirequired,ibutinurseishouldicompleteiassessment 3)iappropriateiassessmentiforiRaynaudiphenomenon;ieatingiproblemsit akeipriority 4)iCORRECT — iprogressiveisystemicisclerosisiisiaiconnectiveitissueidiseaseithaticausesi dysphagiaiandiesophagealirefluxibecauseiofidecreasedimotility;inurseis houldiassessibeforeideterminingitheiappropriateiimp Aiterminallyiilliclientiwithiexcruciatingipainiepisodesicomplainsitheipaini medicationigiveniatinightidoesinotirelieveitheipainiasiwelliasiitidoesiduri ngitheiday.iAichartireviewirevealsithaticlientsireportipainimedicationibei ngilessieffective,ianditheiclientsireceiveimoreimedicationiwheniaiparticu larinurseiisiworking.iWhichiofitheifollowingiactionsishoulditheinurseitak eiFIRST? i1.iSetiupiaihiddenicameraiinitheimedicationiroom.

i2.iAskiphysicianitoiconsideriincreasingitheidosageiofimedicationiatinight . i3.iDetermineihowilongitheiclientihasibeenireceivingitheimedication. i4.iTemporarilyiassignianotherinurseitoigiveialliofitheiPRNimedications.i- iCorrectiAnswer-Strategy:i"FIRST"iindicatesipriority. 1)ipriorityiisicaringiforitheiclientiinipain 2)iclientsicomplainingiofipainiisianiindicationithatithereimayibeiaiproble miwithioneiofitheinurses 3)iassumesithaticlientiisiexperiencingiaitoleranceitoitheimedication 4)iCORRECT — iprimaryifocusiisiclienticomfort;ivalidationiofitheinurseihavingiaisubstanc eiabuseiproblemidoesinotioverrideiqualityiclienticare Theinurseicaresiforiaipatientihospitalizediforiaiheadiinjury.iTheiclientiisir eceivingi0.9%isodiumichlorideiati 100 icc/hiandihasianiindwellingiFoleyica theteriiniplace.iTheinurseinotesitheipatient'siurinaryioutputiisi1,00 0 icciini 3 ihours.iWhichiofitheifollowingiactionsibyitheinurseiisiMOSTiappropriate ? i1.iContactitheiphysician. i2.iDecreaseitheiamountiofifluidsitheipatientiisireceiving.

i3.iAssessitheiclient'simucousimembranes. i4.iMeasureitheiurineispecificigravity.i-iCorrectiAnswer- Strategy:iDetermineiifiassessmentioriimplementationiisiappropriate. 1)icompleteitheiassessmentibeforeicontactingitheiphysician;isymptomsi ofidiabetesiinsipidusiincludeiexcessiveiurineioutput,isevereidehydration ,iexcessiveithirst,ianorexia,iweightiloss 2)iADHideficiencyicausesitheiexcretioniofilargeivolumesiofidiluteiurine;iifi deprivediofifluids,imayicauseishock 3)imayiseeisignsiofidehydration,isuchiasipooriskiniturgoriandidryioricrack edimucousimembranes 4)iCORRECT — ilowispecificigravityi(1.00 1 iandi1.005)iisicharacteristiciofidiabetesiinsipid us;iheadiinjuryicausesiinterferenceiwithiproductioniorireleaseiofiADH;ire cordiIiandiO,iurineispecificigravity,iandidailyiweight;iensureiclient'siintak eiofifluidiandiadministeriDDAVP Theinurseicaresiforiaipatientiwithichestitubes.iTwoidaysiafteriinsertion,it heichestitubeiisiaccidentallyipulledioutiofitheipleuralispace.iWhichiofithei followingiactionsishoulditheinurseitakeiFIRST? i1.iDonisterileiglovesiandireplaceitheitube.

i2.iApplyipressureiwithiaidressingithatiisitentedionioneiside. i3.iInstructitheiclientitoicoughiandideep-breathe. i4.iAuscultateitheilung.i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)iinsertingitheitubeiisiaimedicaliprocedure 2)iCORRECT — idecreasesichanceithatiatmosphericiairiwillienteripleuralispaceiandiallow siforiescapeiofipleuraliair 3)iincreasesitheiamountiofiatmosphericiairithatientersitheipleuralispace 4)ipriorityiisicoveringitheiopening;ilistenitoilungsiafteriemergencyimeasu reiinstituted Aitornadoiroaredithroughiaipopulatediarea,icausingimultipleicasualties.i WhichiofitheifollowingipatientsishoulditheinurseiseeiFIRST? i1.iAipatientiwithiaismallipenetratingiabdominaliwoundicausedibyiflyingi debris. i2.iAipatientiwithibluntitraumaitoitheiabdomenithaticausedibruising. i3.iAipatienticomplainingiofichestipainiwithiasymmetricalichestimoveme ntinoted.

i4.iAipatientiwhoiisiconfusediandirestlessiwithinoivisibleiinjuries.i- iCorrectiAnswer-Strategy:iDetermineitheimostiunstableipatient. 1)imayicauseibleeding;iinjuryidoesinotiappearitoibeilife-threatening 2)isecondipatientithatishouldibeiseen;iobserveiforiecchymosis,iwhichiind icatesiretroperitonealibleedingiintoitheiabdominaliwall 3)iCORRECT — iindicatesiflail;imonitoriforishock,igiveihumidifiedioxygen,imanageipain,i monitoriABGs 4)iappearsimostistable Aimanihospitalizediforialcoholiabuseicomesitoitheinurses'istationiandias ksitheinurseiifiheicanigoitoitheicafeteriaitoigetisomethingitoieat.iWhenito ldithatihisiprivilegesidoinotiincludeivisitingitheicafeteria,itheipatientibec omesiverballyiabusive.iWhichiofitheifollowingiactionsibyitheinurseiisiMO STiappropriate? i1.iTellitheipatientitoilowerihisivoice. i2.iAskitheipatientiwhatiheiwantsifromitheicafeteria. i3.iCalmlyibutifirmlyiescortitheipatientitoihisiroom.

i4.iAssigniainursingiattendantitoiaccompanyitheipatientitoitheicafeteria.i

• iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)idoinotiargue;icarryioutilimit-setting 2)ireinforcesiinappropriateibehavior 3)iCORRECT — ilimit- setting,iensuresisafety;ipatientiwithisubstanceiabuseineedsiconsistent,i undividedistaffiapproach,iclearlyidefinediexpectations,iasiwelliasilimit- setting;iavoidithreatsiandipromises 4)ireinforcesiabusiveibehavior Theinurseipreparesiaiclientiforiaiskinibiopsy.iWhichiofitheifollowingistate ments,iifimadeibyitheiclient,ishoulditheinurseireportitoitheiphysician? i1.i"Iihaveibeenitakingiaspiriniforimyiachingijoints." i2.i"Iiappliedilotionitoimyiskiniafterimyishowerilastinight." i3.i"Iilaidioutiinitheisuniyesterday." i4.i"Iihadicoffeeiandiaisweetirolliforibreakfastithisimorning."i- iCorrectiAnswer-Strategy:iThinkiaboutiwhatitheiwordsimean.

1)iCORRECT — iaspirinicaniincreaseitheiriskiforibleedingiandishouldibeireported 2)idoesinotiaffectitheibiopsy 3)inotiaigoodihealthihabit,ibutiitidoesinotiaffectitheibiopsy 4)iaipunchiorishaveibiopsyiisiusuallyiperformedionitheiskiniandidoesinotir equireiNPO;icleanibiopsyisiteionceiaidayiwithitapiwateriorisaline;ileaveisi teiopen Theinurseicounselsiaiclientidiagnosediwithidegenerativeijointidisease.iIti isiMOSTiimportantiforitheinurseitoiincludeiwhichiofitheifollowingiinstruc tions? i1.i"Placeiyourijointsiinitheipositionioficomfort." i2.i"Placeiyourijointsiiniaiflexediposition." i3.i"Placeiyourijointsiinifulliextension." i4.i"Placeiyourijointsiinitheirifunctionaliposition."i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)imayileaditoilimitationsiinimovement;iplaceiinifunctionaliposition

2)iwouldicauseiflexionicontracturesithatilimitimobility;ionlyiuseiaismallip illowiunderitheiheadiorineck;idoinotiuseilargeipillowsiunderitheiknees;ito ireduceibackidiscomfort,ielevateilegsi 8 - 10 iinches 3)ishouldibeiplacediinicorrectifunctionalipositionitoimaintainimobilityiofi joint 4)iCORRECT — imaintainsimobilityiofijoints Theinurseiisimakingistaffiassignmentsionitheimedical/surgicaliunit.iThein urseishouldiassigniainursingiassistantitoicareiforiwhichiofitheifollowingicl ients? i1.iAiclientidiagnosediwithiaiCVAi 2 iweeksiagoirequiringiassistanceiambul ating. i2.iAiclientidiagnosediwithiCOPDiwhoiisiiniacuteidistressirequiringiassista nceibathing. i3.iAiclientireceivingitotaliparenteralinutritionithroughiaiPICCilineirequiri ngiaidressingichange. i4.iAiclientidiagnosediwithitypei 1 idiabetesionimechanicaliventilationireq uiringiaibath.i-iCorrectiAnswer- Strategy:iAssignitheinursingiassistantitoistableiclientsiwithistandard,iunc hangingiprocedures

1)iCORRECT — istableipatientirequiringiaistandard,iunchangingiprocedure;iinstructinurs ingiassistantiaboutitheihowifaritoiwalkitheiclientiandianyiuntowardioccu rrencesitoireport 2)iclientirequiresiassessment;inotiappropriateiforitheinursingiassistant 3)irequiresiskilliofitheiRN 4)irequiresiskilliofitheiRN Theihomeicareinurseivisitsiaiclientireceivingiwarfarini(Coumadin)i 5 imgiP OidailyiforiDVT.iTheinurseilearnsitheiclientioperatesiaihorseiranch.iItiisiM OSTiimportantiforitheinurseitoiincludeiwhichiofitheifollowingiinstruction s? i1.iRideiwithiaicompanioniandiwearianiidentificationibracelet. i2.iCarryiaicelliphoneiandidressingsianditape. i3.iProvideisignificantiothersiwithiaiwritteniitineraryiforitheiday. i4.iTemporarilyichangeitoiactivitiesithatiareisaferiforiclienti- iCorrectiAnswer- Strategy:i"MOSTiimportant"iindicatesidiscriminationiisirequireditoians weritheiquestion

1)iridingiwithiaicompanioniisihelpfulibutidoesinotispecificallyireduceithei risks;ishouldiwearianiMediciAlertibracelet 2)iCORRECT — ibecauseiofioccupationiandiprescribedianticoagulant,iclientiisiatiriskiforit issueidamage;iinicaseiofiinjury,iapplyipressureitoiwoundiandisummonihe lp 3)iothersiknowingipotentialilocationiisirelevantibutidoesinotireduceirisks 4)itakingitheimedicationiisilong- term;inurseishouldihelpiclientiintegrateiappropriateiinterventionsiintoili festyle Theinurseicaresiforiclientsiinitheioutpatienticlinic.iAiclientiwithiaipacema kericallsitoireportithatiheijustihadianiepisodeiofidizzinessiandishortnessio fibreath.iWhichiofitheifollowingiresponsesibyitheinurseiisiMOSTiimporta nt? i1.i"Whatiisiyouripulse?" i2.i"Whatiwereiyouidoingibeforeitheiepisode?" i3.i"Haveiyouiexperiencedithisibefore?" i4.i"Isitheiareaioveritheipacemakeripainfuliorired?"i-iCorrectiAnswer- Strategy:i"MOSTiimportant"iindicatesipriority.

1)iCORRECT — imayiindicateipacemakerimalfunction;inurseishouldiassessiclient'sicurre ntistatus 2)iassessiificlientiwasicloseitoielectromagneticifieldithatimightiinterferei withifunctioniofipacemaker;imoreiimportantitoiassessicurrentistatus 3)ishouldibeiaskedilateriiniconversation 4)imayiindicateiinfection;imoreiimportantitoiassessicardiacifunctioning Aiclientiisiadmitteditoitheilaboriandiunitiiniaisickle- cellicrisis.iWhichiofitheifollowinginursingiactionsishoulditheinurseitakeiFI RST? i1.iAdministerioxygen. i2.iTurniclientitoirightiside. i3.iBeginianiIViwithinormalisaline. i4.iAdministeriantibiotics.i-iCorrectiAnswer- Strategy:iDetermineitheioutcomeiofieachianswer.iIsiitidesired? 1)isecondiaction;icrisisicausedibyiextensiveiextracellularisickling

2)inoireasonitoiturnitoirightiside;idoinotikeepikneesiandihipsiiniaiflexedip osition 3)iCORRECT — idehydrationiperpetuatesicellisickling;iintakeishouldibeiatileasti 200 icc/h our 4)imoreisusceptibleitoiblood- borneipathogens;ifrequentihandwashing;iavoidipeopleiwithiURI Theinurseicaresiforiailaboringipatient.iTheipatientirequestsisomethingifo ripainiandisaysitoitheinurse,i"I'mireallyiscarediofishots."iWhichiofitheifoll owingiresponsesibyitheinurseiisiBEST? i1.i"Aishotiisiyourionlyioption,ibecauseilaborislowsitheiGIitract." i2.i"Iicanigiveiyouiaipillinow,ibutiitiwillinotilastiasilongiasianiinjection." i3.i"Whatiwasiyouripreviousiexperienceiwithishots?" i4.i"Whatiareiyouiafraidiof?"i-iCorrectiAnswer- Strategy:iRememberitherapeuticicommunication. 1)iisianiaccurateiresponseibutidoesinotiallowitheiclientitoiexpressiherifee lings 2)ioralimedicationiisinotirecommendediinilaboribecauseiofitheidecreasei iniGIimotility

3)iCORRECT — ianiassessmentitoiassistitheinurseiinigatheringiinformationitowardiachie vingipainireliefianditoithisiparticulariclient'sipsychologicalistate;iassessib eforeiintervening 4)ijudgmentaliandinontherapeutic Theinurseionitheimedical/surgicaliunitiadmitsianielderlyiclientiafterithei patientihasiundergoneiaibelow-the- kneeiamputation.iTheinurseiobtainsivitalsisignsiandiassessesithatitheicli entiisiableitoibeiarousedibutiisisleepy.iWhenitheiclientiawakensiandireali zesithatitheiamputationiwasiperformed,itheiclientibeginsitoiscream.iWhi chiofitheifollowingistatementsibyitheinurseiisiMOSTiappropriate? i1.i"Theiphysicianiinformediyouithatitheiamputationiwasirequired." i2.i"I'lligetiyouisomeimedicationisoithatiyouicanirest." i3.i"Yourifamilyiisiwaitingiinitheilobbyitoicomeiseeiyou." i4.i"Sinceiyouiseemiupset,iI'llistayiwithiyou."i-iCorrectiAnswer- Strategy:i"MOSTiappropriate"iindicatesidiscriminationiisirequireditoian sweritheiquestion 1)ifirstistepiofireadjustmentiofichangedibodyiimageiisipsychologicalishoc k;iclientiwillinotibeireceptiveitoireceivingiinformation

2)imoreiimportantiforitheinurseitoistayiwithitheiclient 3)ipassingitheibuck;inurseishouldicareiforiclient 4)iCORRECT — iacknowledgesiclient'sifeelings;inurseishouldistayiwithipatient,ifocusioni hereiandinow,iandidealiwithiclient'siimmediateiproblems TheinurseideterminesithatiwhichiofitheifollowingiclientsiisiMOSTiatiriskit oidevelopigastroesophagealirefluxidiseasei(GERD)? i1.iAi 16 - year- oldiAfricaniAmericanimaleiwhoihadianiNGitubeifori 3 idaysiafterisurgeryif oriairupturediappendix. i2.iAi 30 - year- oldiHispanicifemaleiwithiaidiagnosisioficholelithiasisiandiait- tubeiiniplace. i3.iAi 52 - year- oldiCaucasianifemaleiwhoiisi5'5"italliandiweighsi 185 ipounds. i4.iAi 65 - year- oldiCaucasianimaleiwithiailaryngectomyiforilaryngealicancer.i- iCorrectiAnswer-Strategy:iThinkiaboutieachianswer. 1)iNGitubeiisiairiskifactor;iNGitubeicompromisesiesophagealisphincterifu nctioniandipermitsiacidicistomachicontentsitoienteritheiesophagus

2)ibeingifemaleiisiairiskifactoriforiGERD 3)iCORRECT — iGERDiisigastrointestinalicontentsiflowingibackwardiintoitheiesophagus;i riskifactorsiincludeifemale,ioveritheiageiofi45,iandiobesity;iGERDiappear simoreiofteniiniCaucasians 4)iriskifactorsiincludeiageiandiethnicity;ismokingiisialsoiairiskifactoriforiG ERD Theinurseicaresiforiclientsiinitheiemergencyidepartmentiafterianiearthq uake.iWhichiofitheifollowingiclientsishoulditheinurseiseeiFIRST? i1.iAiclientiati 7 imonths'igestationicomplainingioficrampingiandiblood- streakedidischarge. i2.iAiclientiwithiaidisplacedifractureiofitheirightiradiusiwithibloodiseeping ifromitheiwound. i3.iAiclienticomplainingiofilightheadedness;inurseinotesiclientiisiclammy, ipulsei112,irespirationsi28. i4.iAiclientiwithitypei 1 idiabetesiwhoitookiinsuliniimmediatelyibeforeithei earthquakeiandiisicomplainingiofilightheadedness.i-iCorrectiAnswer- Strategy:i"FIRST"iindicatesipriority. 1)imayibeiiniearlyilabor,istableipatient