NCLEX Practice

1.
1. The nurse is admitting a woman who is scheduled for a total hip replacement. What is the most effective way to initiate the health interview?
- A.
  
  Sit quietly until the client initiates the conversation.
- B.
  
  Start the interview with easy questions to build a rapport.
- C.
  
  Determine whether there are any family available to assist her.
- D.
  
  Focus on the diagnosis and its effect on the client.
Correct Answer
B. Start the interview with easy questions to build a rapport.

Explanation
The best approach to a good interview is to start with the easy, less personal questions while building a rapport. Waiting for the client to initiate the conversation is not an efficient use of time; furthermore, the client will not know what information the nurse needs. Assume the client can provide an accurate health history unless there are indications that he or she cannot give accurate information. Information about the current health problem and its impact can be assessed after rapport is established.

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2.

At the beginning of the shift, the nurse receives a report on a client. He is receiving IV therapy at 125 mL/hr. The nasogastric tube is patent and draining green drainage at about 75 mL/hr. New physician orders include the following: Vancomycin (Vancocin) 500 mg IVPB in 50 mL D5W over 60 minutes, every 8 hours. Metoclopramide (Reglan) 10 mg IVPB in 50 mL D5W over 30 minutes, every 8 hours. One unit packed red blood cells to run concurrent with the IV; infuse unit over 4 hours. Irrigate the nasogastric tube with 30 mL NS every 2 hours. How many milliliters should the nurse document as the intake for the 8-hour shift?

Correct Answer
1470 mL

Explanation
All of the listed IV fluids should be infused within the nurse’s 8-hour shift. The nasogastric tube will have been irrigated four times.
IV @ 125 mL/hr x 8 hours = 1000 mL
Vancomycin IVPB = 50 mL
Reglan IVPB = 50 mL
Packed RBCs = 250 mL
NG irrigation = 30 mL x 4 = 120 mL
Total = 1470 mL

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NCLEX Practice

The nurse is admitting a woman who is scheduled for a total hip replacement. What is the most effective way to initiate the health interview?