Here are the Answers to NCLEX Preparation Course - Critical Thinking IV (11-20) -->
11. A 38-year old man was brought to the emergency room due to profuse bleeding from chest stab wound. Assessments of his vital signs are follows: BP is 80/40 mmHg, PR is 110 bpm, and RR is 28. The nurse expects which of the following potential problems?
a) cardiogenic shock
b) hypovolemic shock
c) neurogenic shock
d) septic shock
12. A 60-year old clients report to the nurse that he has rash on his back and right flank. The nurse observes elevated round blister-like lesions that are filled with clear fluid. When documenting the findings, what medical term should the nurse use to describe these lesions?
13. When caring for a client in restraints, which of the following is not appropriate nursing action?
a) ensure that written consent for restraint application has been secured from relatives
b) apply soft restraints
c) secure restraints on the side rails
d) check client and area of restraints application every 15-20 minutes
14. Which of the following is incorrect statement about incident reports?
a) it is a tool used as means of identifying and improving care
b) the report form should be placed in the client's record
c) it is not a substitute for complete entry in the client's record regarding the incident
d) it should be complete, accurate and factual
15. In which of the following situations does the nurse practice beneficence?
a) she reports child abuse to the local authority
b) she advocates for the client from the practitioner who practices drug abuse
c) she refers the abused woman to support group
d) she practices universal precaution when caring for clients
16. The nurse from obstetric department is floated to the emergency department. Who among these clients will the charge nurse appropriately assign to the nurse?
a) the client receiving blood transfusion
b) the client with acute asthmatic attack
c) the client who is confused and agitated
d) the client who has chest injury
17. The client has severe jaundice. Which of the following should the nurse not include when giving health teachings?
a) keep the environment warm
b) cut fingernails short and smoothen them
c) wash skin with water and mild soap
d) change clothing as necessary
18. Which of the following herbal medicines is used to relieved stress, boost energy, and provides digestive support?
a) feverfew
b) aloe vera
c) cranberry
d) ginseng
19. An 88-year old client complains, "I frequently wake-up at night." What advise would the nurse give to the client?
a) drink milk instead of coffee at bedtime
b) limit your fluid intake to 1 liter a day
c) avoid drinking too much fluid before bedtime
d) drink fluids only when you're thirsty
20. Who among these clients may be assigned by the RN to the CNA?
a) the client on blood transfusion started 2 hours ago, whose BP needs to be checked
b) the client who requires nasogastric tube feedings every 3 hours
c) the client whose bladder is distended and requires catheterization
d) the client with tracheostomy who requires suctioning as necessary
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NCLEX Preparation Course - Critical Thinking Exercises IV (Questions 11-20)
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