Here are the Answers to NCLEX Preparation Course - Critical Thinking III (11-20) -->
11. Which of the following is a characteristic manifestation of rubeola?
a) koplik's spot in the mouth
b) clusters of vesicles in the trunk
c) desquamation of skin at the tips of the fingers and toes
d) linear burrows in the skin
12. Which of the following clients should be given highest priority by the nurse?
a) the client in the manic phase of bipolar disorder
b) the client whose severe depression is now resolving
c) the client with severe anxiety
d) the client with compulsive behavior
13. In which of the following may the nurse be charged for negligence?
a) the client's nasogastric tube feeding has been delayed for one hour
b) a medication has been delayed because of incomplete physician's order
c) the client's abdominal binder loosened while he was ambulating along the hallway
d) the nurse allowed the client to read his chart
14. The patient is on SaO2 monitor. The nurse should intervene in which of the following situations?
a) if the finger is wiped with alcohol before placing the sensor
b) if the sensor is placed on the little finger
c) if an arm board is kept on the same hand of the client, where the sensor is placed
d) if the sensor is placed alternately in the second, third, and fourth fingers
15. The client is on total parenteral nutrition (TPN) therapy at home. Which of the following statements indicates that the client understands the health teachings?
a) I will check my capillary blood sugar daily
b) I will check my urine ketones
c) I will check my pulse daily
d) I will check my weight daily
16. The nurse should intervene when she observes the CNA (Certified Nursing Assistant) doing which of the following actions?
a) the CNA is talking loudly to an elderly client
b) the CNA checks the temperature of water before bathing an elderly
c) the CNA assisting an elderly who is ambulating along the hallway
d) the CNA applies lotion to the skin of an elderly
17. The hospital is conducting a drill on triage for registered nurses. Which of the following clients should the nurse attend first?
a) an 80-year old client whose trachea is deviated to the left
b) a 15-year old with multiple fractures of the right femur
c) a 45-year old client with active bleeding on the left wrist
d) a 55-year old client with a closed head injury with fixed and dilated pupils
18. A female nursing assistant tells the nurse that she is not comfortable about a young adolescent's behavior and will not provide care for him. The adolescent has poor impulse control, but has never "acted out" or assaulted the nursing assistant. Which of these goals should have a priority in the nurse's dealing with the nursing assistant?
a) to have the assistant care for the client
b) to have the assistant identify her feelings about aggressive behavior
c) to have the assistant confront the patient's about his behavior
d) to have the assistant admit the need for a referral for counseling services
19. A client with long-term debilitating illness shouts, "Get out of here. You're always bothering me with something." Which response by the nurse is most appropriate?
a) you don't have to yell. I'm sorry you feel like I've bothered you
b) Ill go but I'll be back in a little while to find out what is bugging you
c) I'm going to have to ask you to be quiet as there are other clients in this unit
d) something is bothering you. I'll be glad to listen if you would like to talk
20. The nursing assistant reports to the charge nurse that she saw the RN putting opioid in his pocket. Which of the following action is essential for the charge nurse to do?
a) review the charts of the RN's patients, to check if medications were given
b) ask more information from the nursing assistant (CNA) about the incident
c) call the security
d) ignore what the CNA has informed
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NCLEX Preparation Course - Critical Thinking Exercises III (Questions 11-20)
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