NCLEX RN Practice Questions 13 (Exam Mode) By RNpedia.Com
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The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?
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The tube will allow for equalization of the lung expansion.
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Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
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Chest tubes relieve pain associated with a collapsed lung.
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Chest tubes assist with cardiac function by stabilizing lung expansion.
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Mark the letter of the letter of choice then click on the next button. Score will be posted as soon as the you are done with the quiz. You got 30 minutes to finish the exam. Good luck!
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- 2.
A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:
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Mother’s educational level
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Infant’s birth weight
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Size of the mother’s breast
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Mother’s desire to breastfeed
Correct Answer
A. Mother’s desire to breastfeedExplanation
Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success.Rate this question:
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- 3.
The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?
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The presence of scant bloody discharge
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Frequent urination
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The presence of green-tinged amniotic fluid
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Moderate uterine contractions
Correct Answer
A. The presence of green-tinged amniotic fluidExplanation
Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions.Rate this question:
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- 4.
The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?
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Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
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Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
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Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
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Duration is measured by timing from the peak of one contraction to the end of the same contraction.
Correct Answer
A. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.Explanation
Duration is measured from the beginning of one contraction to the end of the same contraction. Answer choice "Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction."refers to frequency. Answer choice "Duration is measured by timing from the end of one contraction to the beginning of the next contraction." is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is NOT measured from the peak of the contraction to the end.Rate this question:
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- 5.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:
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Maternal hypoglycemia
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Fetal bradycardia
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Maternal hyperreflexia
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Fetal movement
Correct Answer
A. Fetal bradycardiaExplanation
The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, other answer choices are incorrect.Rate this question:
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- 6.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
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Insulin requirements moderate as the pregnancy progresses.
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A decreased need for insulin occurs during the second trimester.
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Elevations in human chorionic gonadotrophin decrease the need for insulin.
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Fetal development depends on adequate insulin regulation.
Correct Answer
A. Fetal development depends on adequate insulin regulation.Explanation
Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them.Rate this question:
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- 7.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
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Providing a calm environment
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Obtaining a diet history
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Administering an analgesic
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Assessing fetal heart tones
Correct Answer
A. Providing a calm environmentExplanation
A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers obtaining a diet history and administering an analgesic are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation .Rate this question:
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- 8.
A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:
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Down syndrome
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Respiratory distress syndrome
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Turner’s syndrome
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Pathological jaundice
Correct Answer
A. Down syndromeExplanation
The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Other answer choices are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder.Rate this question:
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- 9.
A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:
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Magnesium sulfate
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Calcium gluconate
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Dinoprostone (Prostin E.)
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Bromocrystine (Pardel)
Correct Answer
A. Dinoprostone (Prostin E.)Explanation
The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, other answer choices are incorrect. Pardel was used at one time to dry breast milkRate this question:
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- 10.
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:
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Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
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Stop the infusion of magnesium sulfate and contact the physician
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Slow the infusion rate and turn the client on her left side
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Administer calcium gluconate IV push and continue to monitor the blood pressure
Correct Answer
A. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressureExplanation
The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. There is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity.Rate this question:
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- 11.
Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?
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An affected newborn has unaffected parents.
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An affected newborn has one affected parent.
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Affected parents have a one in four chance of passing on the defective gene.
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Affected parents have unaffected children who are carriers.
Correct Answer
A. Affected parents have a one in four chance of passing on the defective gene.Explanation
Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer choice "An affected newborn has unaffected parents" is incorrect because, to have an affected newborn, the parents must be carriers. Answer choice "An affected newborn has one affected parent" is incorrect because both parents must be carriers. Answer choice "Affected parents have unaffected children who are carriers" is incorrect because the parents might have affected children.Rate this question:
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- 12.
A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:
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Because it is a state law
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To detect cardiovascular defects
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Because of her age
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To detect neurological defects
Correct Answer
A. To detect neurological defectsExplanation
Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer choice "Because it is a state law ". It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answer choices "To detect cardiovascular defects " and "Because of her age " are incorrect.Rate this question:
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- 13.
A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:
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There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
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Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
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It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
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Fetal growth is arrested if thyroid medication is continued during pregnancy.
Correct Answer
A. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.Explanation
During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer choice "There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone" is incorrect because there could be a need for thyroid medication during pregnancy. Answer choice "It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism" is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer choice "Fetal growth is arrested if thyroid medication is continued during pregnancy" is incorrect.Rate this question:
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- 14.
The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:
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An apical pulse of 100
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An absence of tonus
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Cyanosis of the feet and hands
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Jaundice of the skin and sclera
Correct Answer
A. Cyanosis of the feet and handsExplanation
Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby should have muscle tone. Jaundice immediately after birth is pathological jaundice and is abnormal.Rate this question:
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- 15.
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for: a
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Supplemental oxygen
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Fluid restriction
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Blood transfusion
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Delivery by Caesarean section
Correct Answer
A. Supplemental oxygenExplanation
Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, other answer choices are incorrect.Rate this question:
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- 16.
A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:
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Increasing fluid intake
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Limiting ambulation
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Administering an enema
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Withholding food for 8 hours
Correct Answer
A. Increasing fluid intakeExplanation
Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, other answer choices are incorrect.Rate this question:
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- 17.
An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?
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14 pounds
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16 pounds
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18 pounds
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24 pounds
Correct Answer
A. 24 poundsExplanation
By 1 year of age, the infant is expected to triple his birth weight. Other answer choices are incorrect because they are too low.Rate this question:
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- 18.
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
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Determines the lung maturity of the fetus
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Measures the activity of the fetus
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Shows the effect of contractions on the fetal heart rate
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Measures the neurological well-being of the fetus
Correct Answer
A. Measures the activity of the fetusExplanation
A nonstress test is done to evaluate periodic movement of the fetus. It is NOT done to evaluate lung maturity . An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does NOT measure neurological well-being of the fetus.Rate this question:
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- 19.
A full-term male has hypospadias. Which statement describes hypospadias?
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The urethral opening is absent.
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The urethra opens on the dorsal side of the penis.
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The penis is shorter than usual.
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The urethra opens on the ventral side of the penis.
Correct Answer
A. The urethra opens on the dorsal side of the penis.Explanation
Hypospadia is a condition in which there is an opening on the dorsal side of the penis. Hypospadia does NOT concern the urethral opening. The size of the penis is not affected. The opening is on the dorsal side, not the ventral side.Rate this question:
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- 20.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
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Alteration in coping related to pain
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Potential for injury related to precipitate delivery
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Alteration in elimination related to anesthesia
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Potential for fluid volume deficit related to NPO status
Correct Answer
A. Alteration in coping related to painExplanation
Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix. There is no data to indicate that the client has had anesthesia or fluid volume deficit.Rate this question:
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- 21.
The client with varicella will most likely have an order for which category of medication?
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Antibiotics
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Antipyretics
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Antivirals
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Anticoagulants
Correct Answer
A. AntiviralsExplanation
Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is NOT treated with antibiotics or anticoagulants . The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer antipyretics is incorrect.Rate this question:
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- 22.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
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Nitroglycerin
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Ampicillin
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Propranolol
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Verapamil
Correct Answer
A. AmpicillinExplanation
Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no indication for an antibiotic such as Ampicillin.Rate this question:
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- 23.
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
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Avoid exercise because it fatigues the joints.
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Take prescribed anti-inflammatory medications with meals.
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Alternate hot and cold packs to affected joints.
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Avoid weight-bearing activity.
Correct Answer
A. Take prescribed anti-inflammatory medications with meals.Explanation
Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.Rate this question:
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- 24.
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?
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Meperidine 100mg IM q 4 hours PRN pain
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Mylanta 30 ccs q 4 hours via NG
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Cimetadine 300mg PO q.i.d.
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Morphine 8mg IM q 4 hours PRN pain
Correct Answer
A. Morphine 8mg IM q 4 hours PRN painExplanation
Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis.Rate this question:
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- 25.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
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Hallucinogenic drugs create both stimulant and depressant effects.
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Hallucinogenic drugs induce a state of altered perception.
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Hallucinogenic drugs produce severe respiratory depression.
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Hallucinogenic drugs induce rapid physical dependence.
Correct Answer
A. Hallucinogenic drugs induce a state of altered perception.Explanation
Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Other answer choices are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependenceRate this question:
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Mar 21, 2023Quiz Edited by
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Feb 12, 2011Quiz Created by
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