NCLEX Test: Foundation Of Practice Part II
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Answers and Rationales: Foundation of Practice Part II
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- 1.
A client with a history of emphysema is now terminally ill with cancer of the esophagus. The client is weak, dyspneic, emaciated, and apathetic. The plan of care includes a soft diet, modified postural drainage, and nebulizer treatments. The nursing care plan for this client should give priority to:
- A.
Intake and output
- B.
Diet and nutrition
- C.
Hygiene and comfort
- D.
Body mechanics and posture
Correct Answer
C. Hygiene and comfortExplanation
The client in this scenario is weak, dyspneic, emaciated, and apathetic, indicating that they are in a very debilitated state. Given their terminal illness and symptoms, the priority of the nursing care plan should be to provide comfort and maintain hygiene. This is important for the client's overall well-being and quality of life in their final stages. While intake and output, diet and nutrition, and body mechanics and posture are important aspects of care, they may not take priority over providing comfort and maintaining hygiene in this specific situation.Rate this question:
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- 2.
A terminally ill client is visited frequently by the spouse, a 16-year-old daughter, and a 20-year-old son. In view of the client’s extreme weakness and dyspnea, nursing care plans should include:
- A.
Allowing self-activity whenever possible
- B.
Encouraging family members to feed and assist the client
- C.
Limiting family visiting hours to the evening before the client sleeps
- D.
Planning all necessary care at one time with long rest periods in between
Correct Answer
B. Encouraging family members to feed and assist the clientExplanation
Encouraging family members to feed and assist the client is the correct answer because it promotes a sense of support and involvement from the family, which can be comforting for the terminally ill client. It also allows the client to conserve energy and focus on their basic needs, such as eating, without exerting themselves too much. This approach acknowledges the client's extreme weakness and dyspnea, and ensures that they receive the necessary care and assistance while still maintaining a level of independence.Rate this question:
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- 3.
When preparing a client for ambulation with crutches, the nurse should recognize the need for further teaching when the client states, “ I must practice:
- A.
Sitting down and standing up.”
- B.
Ambulating several hours a day.”
- C.
Standing and maintaining balance.”
- D.
Doing active exercises for muscle strengthening.”
Correct Answer
B. Ambulating several hours a day.”Explanation
The need for further teaching is recognized when the client states, "Ambulating several hours a day." This statement indicates a misunderstanding of the appropriate amount of ambulation with crutches. Ambulating for several hours a day would be excessive and could lead to fatigue and further injury. The correct amount of ambulation with crutches should be discussed and explained to the client.Rate this question:
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- 4.
Rehabilitation plans a client who has paraplegia as a result of spinal cord severance:
- A.
Should be left up to the client and the clients family
- B.
Should be considered and planned for early in the client’s care
- C.
Are not necessary, because the client will return to former activities
- D.
Are not necessary, because the client will probably not be able to work again
Correct Answer
B. Should be considered and planned for early in the client’s careExplanation
When a client has paraplegia as a result of spinal cord severance, rehabilitation plans should be considered and planned for early in the client's care. This is because rehabilitation plays a crucial role in helping the client adapt to their new condition, regain independence, and improve their quality of life. Early intervention allows for the development of a comprehensive rehabilitation plan that can address the client's physical, emotional, and social needs. By starting rehabilitation early, the client has a better chance of achieving optimal outcomes and maximizing their functional abilities.Rate this question:
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- 5.
A client is transferred to a rehabilitation unit following a CVA. A basic concept about rehabilitation is:
- A.
Rehabilitation needs are best met by the client’s family and community resources
- B.
Rehabilitation is a specially area with unique methods for meeting the client’s needs
- C.
Rehabilitation needs, immediate or potential, are exhibited by all clients with a health problem
- D.
Rehabilitation is unnecessary for clients returning to their usual activities following hospitalization
Correct Answer
C. Rehabilitation needs, immediate or potential, are exhibited by all clients with a health problemExplanation
The correct answer suggests that all clients with a health problem exhibit immediate or potential rehabilitation needs. This implies that rehabilitation is not limited to specific individuals or conditions, but is a universal requirement for anyone facing health challenges. It emphasizes the importance of addressing rehabilitation needs in order to optimize the client's recovery and overall well-being.Rate this question:
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- 6.
The nursing process can be defined as the:
- A.
Implementation of nursing care by the nurse
- B.
Steps the nurse employs to provide nursing care goals
- C.
Process the nurse to determine nursing goal
- D.
Activities a nurse employs to identify a client’s problem.
Correct Answer
B. Steps the nurse employs to provide nursing care goalsExplanation
The nursing process refers to the systematic steps that a nurse follows to provide nursing care goals. These steps include assessing the client's health status, diagnosing the client's health problems, planning and implementing interventions to address those problems, and evaluating the outcomes of the interventions. By employing these steps, nurses are able to provide effective and individualized care to their clients, ultimately aiming to improve their health and well-being.Rate this question:
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- 7.
To utilize the nursing process, the nurse must first:
- A.
Identify goals for nursing care
- B.
State the client’s nursing needs
- C.
Obtain information about the client
- D.
Evaluation the effectiveness of nursing actions
Correct Answer
C. Obtain information about the clientExplanation
In order to utilize the nursing process effectively, the nurse must first obtain information about the client. This step is crucial as it allows the nurse to gather relevant data about the client's health status, medical history, current symptoms, and any other pertinent information that will help in identifying their nursing needs and formulating appropriate goals for nursing care. Without obtaining this information, the nurse would not have a comprehensive understanding of the client's condition and would not be able to provide appropriate and individualized care.Rate this question:
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- 8.
A nursing diagnosis represents the:
- A.
Proposed plan of care
- B.
Client’s health problems
- C.
Assessment of client data
- D.
Actual nursing intervention
Correct Answer
B. Client’s health problemsExplanation
A nursing diagnosis represents the client's health problems. This refers to the identification and analysis of a client's health issues or potential health issues based on the assessment of client data. It helps nurses to understand and prioritize the client's needs and develop an appropriate plan of care. The nursing diagnosis guides the actual nursing interventions that are implemented to address the client's health problems.Rate this question:
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- 9.
The nurse who collaborates directly with the client to establish and implement a plan of care is the:
- A.
Primary nurse
- B.
Nurse clinician
- C.
Clinical specialist
- D.
Nurse coordinator
Correct Answer
A. Primary nurseExplanation
The primary nurse is the correct answer because they are the nurse who directly works with the client to establish and implement a plan of care. They collaborate with the client to assess their needs, develop a care plan, and coordinate the delivery of care. The primary nurse maintains continuity of care and builds a therapeutic relationship with the client, ensuring that their individual needs are met.Rate this question:
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- 10.
The determine factor in the revision of a nursing care plan is the:
- A.
Time available for care
- B.
Validity of the diagnoses
- C.
Method for providing care
- D.
Effectiveness of the interventions
Correct Answer
D. Effectiveness of the interventionsExplanation
The effectiveness of the interventions is the most important factor in revising a nursing care plan. This means that the nurse must evaluate whether the interventions implemented are achieving the desired outcomes and making a positive impact on the patient's health. If the interventions are not effective, the nurse may need to modify or change them to ensure that the patient receives the best possible care. The other factors mentioned, such as time available for care, validity of the diagnoses, and method for providing care, are also important considerations, but they are secondary to the effectiveness of the interventions.Rate this question:
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- 11.
A need for cognitive learning becomes apparent when an adolescent, newly diagnosed as having diabetes mellitus, asks:
- A.
“What is diabetes?”
- B.
“Can I still be a cheerleader?”
- C.
“How do I give myself an injection?”
- D.
“When do I test my blood for glucose?”
Correct Answer
A. “What is diabetes?”Explanation
The question "What is diabetes?" indicates a need for cognitive learning because the adolescent is seeking information and understanding about their newly diagnosed condition. This question suggests that they are looking to gain knowledge about diabetes and its implications for their daily life. By asking this question, they are showing a willingness to learn and take responsibility for their health.Rate this question:
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- 12.
Developing independence is a primary goal for a client with hemiplegia. The nurse can motivate the client by:
- A.
Establishing long-range goals for the client
- B.
Reinforcing success in task accomplished
- C.
Pointing out errors and helping to correct them
- D.
Demonstrating ways the client can regain independence
Correct Answer
B. Reinforcing success in task accomplishedExplanation
Reinforcing success in tasks accomplished is an effective way to motivate a client with hemiplegia to develop independence. By acknowledging and praising the client's achievements, the nurse can boost their self-confidence and encourage them to continue working towards their goals. This positive reinforcement can help the client feel empowered and motivated to take on new challenges and become more independent in their daily activities.Rate this question:
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- 13.
A client is receiving an antihypertensive drug intravenously for control severe hypertension. The client’s blood pressure is unstable and is at 160/94 before the infusion. Fifteen minutes after the infusion is started the blood pressure rises to 180/100. The response to the drug would be describe as a (n):
- A.
Allergic response
- B.
Synergistic response
- C.
Paradoxical response
- D.
Individual hypersusceptibility
Correct Answer
C. Paradoxical responseExplanation
A paradoxical response occurs when a drug has the opposite effect of what is expected. In this case, the antihypertensive drug is intended to lower blood pressure, but instead, the client's blood pressure rises after the infusion. This unexpected and opposite response is considered a paradoxical response.Rate this question:
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- 14.
Occurrence of a anaphylactic reaction after receiving penicillin indicates that the client has:
- A.
An acquired atopic sensitization
- B.
Passive immunity to the penicillin allergen
- C.
Antibodies to penicillin developed after earlier use of the drug
- D.
Developed potent bivalent antibodies when the IV administration was started
Correct Answer
C. Antibodies to penicillin developed after earlier use of the drugExplanation
The occurrence of an anaphylactic reaction after receiving penicillin indicates that the client has developed antibodies to penicillin after an earlier use of the drug. Anaphylactic reactions are severe allergic reactions that occur when the immune system overreacts to an allergen, in this case, penicillin. The development of antibodies suggests that the client has been sensitized to penicillin and their immune system recognizes it as a foreign substance, triggering an allergic response. This reaction is not indicative of acquired atopic sensitization or passive immunity to the penicillin allergen. The mention of IV administration and potent bivalent antibodies is not relevant to the explanation.Rate this question:
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- 15.
A 35-year-old professional golfer is brought to the emergency room for a bee sting. The client has a history of allergies to bees and is having trouble breathing. The nurse is aware that this client can expire from:
- A.
Ischemia
- B.
Asphyxia
- C.
Lactic acidosis
- D.
Antihistamenia
Correct Answer
B. AsphyxiaExplanation
Asphyxia is the correct answer because the client is experiencing difficulty breathing due to an allergic reaction to a bee sting. Asphyxia refers to the condition where there is a lack of oxygen or excess of carbon dioxide in the body, leading to suffocation. In severe cases, asphyxia can result in respiratory failure and death if not promptly treated.Rate this question:
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- 16.
A client has an anaphylactic reaction within the first half hour after an IV infusion containing ampicillin is started. The nurse understands that the symptoms occurring during an anaphylactic reaction are the result of:
- A.
Respiratory depression and cardiac standstill
- B.
Construction of capillaries and decreased peripheral resistance
- C.
Bronchial constriction and decreased peripheral resistance
- D.
Decreased cardiac output and dilation of major blood vessels
Correct Answer
C. Bronchial constriction and decreased peripheral resistanceExplanation
During an anaphylactic reaction, the immune system overreacts to the presence of ampicillin, triggering the release of histamine and other chemicals. Bronchial constriction occurs as a result of the histamine release, leading to difficulty in breathing. Additionally, the release of chemicals causes the blood vessels to dilate, resulting in decreased peripheral resistance. This combination of bronchial constriction and decreased peripheral resistance leads to symptoms such as wheezing, shortness of breath, and decreased blood pressure.Rate this question:
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- 17.
At the conclusion of visiting hours, the mother of a 14-year-old female scheduled for orthopedic surger5y the following day hands the nurse a bottle of capsules and says, “These are for my daughter’s allergy. Will you be sure she takes one about 9 tonight?” the nurse’s best response would be:
- A.
"One capsule at 9 PM? Of course, I will give it to her.”
- B.
“Did you ask the doctor if she should have this tonight? “
- C.
I am certain the doctor knows about your daughter’s allergy.”
- D.
“I will ask your daughter’s doctor to write an order so I can give this medication to her.”
Correct Answer
D. “I will ask your daughter’s doctor to write an order so I can give this medication to her.”Explanation
The nurse's best response would be to ask the daughter's doctor to write an order for the medication. This ensures that the nurse is following proper protocol and obtaining permission from the doctor before administering the medication. It also shows that the nurse is prioritizing the safety and well-being of the patient.Rate this question:
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- 18.
The physician orders filgrastim (Neupogen) 5 mcg/kg per day by injection for a client who weighs 132 pounds. The vial label reads Neupogen 300 mcg/ml. the nurse should administer:
- A.
0.5 ml
- B.
0.75 ml
- C.
1.0 ml
- D.
1.25 ml
Correct Answer
C. 1.0 mlExplanation
The physician has ordered filgrastim (Neupogen) at a dose of 5 mcg/kg per day. The client weighs 132 pounds, which is approximately 60 kilograms. Therefore, the total dose of filgrastim needed is 300 mcg (5 mcg/kg x 60 kg). The vial label states that there is 300 mcg of Neupogen in 1 ml. To administer the total dose of 300 mcg, the nurse should administer 1 ml (300 mcg/300 mcg/ml). Therefore, the correct answer is 1.0 ml.Rate this question:
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- 19.
An infant is to receive thyroxine sodium, 0.35 mg qd po. The medication is available in elixir form, 0.25 mg/ml. the nurse should administer:
- A.
0.6 ml
- B.
1.0 ml
- C.
1.4 ml
- D.
1.6 ml
Correct Answer
C. 1.4 mlExplanation
The infant is prescribed to receive 0.35 mg of thyroxine sodium per day. The medication is available in elixir form with a concentration of 0.25 mg/ml. To calculate the volume of medication to be administered, we divide the prescribed dose by the concentration of the medication. Therefore, 0.35 mg / 0.25 mg/ml = 1.4 ml. Hence, the nurse should administer 1.4 ml of the medication.Rate this question:
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- 20.
The physician orders atropine, gr 1/300 IM preoperatively for a 7 year-old with excessive respiratory secretions who is schedule to have an exploratory laparotomy. The vial reads “atropine 0.4 mg/ml.” the nurse should administer:
- A.
0.25 ml
- B.
0.5 ml
- C.
0.75 ml
- D.
1.0 ml
Correct Answer
B. 0.5 mlExplanation
The physician orders atropine, gr 1/300 IM preoperatively for a 7-year-old with excessive respiratory secretions who is scheduled to have an exploratory laparotomy. The vial of atropine reads "atropine 0.4 mg/ml." To administer the correct dose, the nurse should calculate the amount of atropine needed based on the physician's order and the concentration of the medication in the vial. Since the physician ordered gr 1/300 of atropine, which is equivalent to 0.00333 mg, and the concentration of atropine in the vial is 0.4 mg/ml, the nurse should administer 0.5 ml of atropine to provide the correct dose.Rate this question:
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- 21.
A 9-year-old is about to have surgery. The physician orders meperidine (Demerol), 20 mg, IV preoperatively. The container reads “50 mg/ml.” the nurse should administer:
- A.
0.4 ml
- B.
0.6 ml
- C.
0.8 ml
- D.
1.0 ml
Correct Answer
A. 0.4 mlExplanation
The physician orders 20 mg of meperidine (Demerol) and the concentration of the medication in the container is 50 mg/ml. To determine the volume to be administered, we divide the ordered dose (20 mg) by the concentration (50 mg/ml). This calculation gives us 0.4 ml, which is the correct volume to be administered.Rate this question:
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- 22.
The physician orders 375 mg ampicillin IV q6h for a 5-month-old with recurring respiratory infections. The drug is supplied as 500 mg of powder in a vial. The directions are mix the powder with 1.8-ml diluents, which yields 250 mg/ml. the nurse should administer:
- A.
0.75 ml
- B.
1.25 ml
- C.
1.50 ml
- D.
1.75 ml
Correct Answer
C. 1.50 mlExplanation
The physician has ordered 375 mg of ampicillin to be administered every 6 hours. The drug is supplied as 500 mg of powder in a vial, which is mixed with 1.8 ml of diluents to yield a concentration of 250 mg/ml. To calculate the amount to be administered, we divide the ordered dose (375 mg) by the concentration (250 mg/ml). This gives us 1.5 ml, which is the amount the nurse should administer.Rate this question:
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- 23.
A client is schedule to receive phenytoin (Dilantin) 100 mg, orally at 6 PM bit is having difficulty swallowing capsules. The nurse should:
- A.
Insert a rectal suppository containing 100 mg phenytoin
- B.
Open the capsule and sprinkle the powder in a cup of water
- C.
Administer 4 ml of phenytoin suspension containing 125 mg/ 5 ml
- D.
Obtain a change in the prescribed administration route to allow IM administration
Correct Answer
C. Administer 4 ml of phenytoin suspension containing 125 mg/ 5 mlExplanation
The correct answer is to administer 4 ml of phenytoin suspension containing 125 mg/ 5 ml. This option provides an alternative route of administration that does not require swallowing capsules. The suspension can be easily administered orally, allowing the client to receive the prescribed medication without difficulty.Rate this question:
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- 24.
A pregnant client is now in the third trimester. The client tells the nurse she wants to have general anesthesia for delivery. The nurse’s best response would be :
- A.
“You are worried about to much pain”
- B.
“You want general anesthesia for delivery?”
- C.
“I will tell your doctor about this request.”
- D.
“I can understand that; labor is uncomfortable.”
Correct Answer
B. “You want general anesthesia for delivery?”Explanation
The nurse's best response would be "You want general anesthesia for delivery?" because it shows that the nurse is actively listening to the client's request and acknowledging it. This response allows the nurse to gather more information about the client's reasons for wanting general anesthesia and discuss the potential risks and benefits with the client. It also shows empathy and understanding towards the client's concerns.Rate this question:
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- 25.
When promoting affective learning (developing attitudes) in client with a newly diagnosed disease, the must first consider the influence of the:
- A.
Client's past experiences.
- B.
Total stress of the situation.
- C.
Client's personal resources.
- D.
Type of onset of the disease.
Correct Answer
A. Client's past experiences.Explanation
When promoting affective learning in a client with a newly diagnosed disease, it is important to consider the influence of the client's past experiences. This is because past experiences can shape the client's attitudes and beliefs, which in turn can affect their ability to learn and adapt to the new situation. By understanding the client's past experiences, healthcare professionals can tailor their approach to address any fears, misconceptions, or negative attitudes that may hinder the learning process. This can help create a supportive and conducive learning environment for the client.Rate this question:
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