NCLEX Review about Ear Infection 41-45

Welcome to NCLEX Review about Ear Infection. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination:

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


41. A nurse is preparing a plan of care for a client being admitted to the hospital with exacerbation of Meniere's disease. Which of the following would the nurse include in the plan of care?

a) increase fluid intake to 3000 ml a day
b) tell the client to avoid moving the head suddenly
c) maintain a quiet environment, and allow the client to read and watch TV
d) increase foods high in sodium in the diet

42. A nurse is performing an assessment of a client suspected of having mastoiditis. Which finding would the nurse expect to note if this disorder is present?

a) an elevated temperature
b) a red, dull, thick, and immobile tympanic membrane
c) a clear tympanic membrane
d) a transparent tympanic membrane

43. A nurse is performing an admission assessment of a client with a disorder involving the inner ear. Which of the following questions will the nurse ask the client to determine if the common symptom of this type of ear disorder is present?

a) do you have any hearing loss?
b) do you have any itching around your ear?
c) do you have any ringing in the ears?
d) do you have any pain in the ear?

44. A new nursing graduate has been hired by the health care clinic to assist in conducting hearing tests in a local neighborhood. The clinic nurse is observing the nursing graduate perform a voice test to assess hearing in a client. Which of the following observations indicates that the graduate is performing the procedure correctly?

a) start 10 feet away from the client to determine if the client can hear clearly
b) asks the cleint to block one ear, quietly whispers a statement, and asks the client to repeat it
c) whispers a statement with the back facing the client
d) asks the client to block the ears, faces the client, verbalizes a statement, and asks the client to repeat the statement

45. A clinic nurse receives a telephone call form a client who states that an insect has somehow flown into her ear and that a buzzing sound can be heard. The client asks the nurse how to remove the insect. Which of the following instructions should the nurse initially provide to the client?

a) have her spouse irrigate ear to kill the insect
b) use a flashlight to try to coax the insect out of the ear
c) instill antibiotic eardrops if they are available
d) get into the shower and allow the ear to run into the ear to flush out the insect








NCLEX Review:
Answers and Rationale

41) B

Exacerbation of Ménière's disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects.

42) B

- Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

43) C

- Tinnitus is the most common complaint of clients with otological disorders, especially those involving the inner ear. This symptom can range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. The client may experience some pain or hearing loss, depending on the disorder, but these are not the most common symptoms. Itching around the ear may be associated with a disorder other than an inner ear disorder.

44) B

- In a voice test, the nurse stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Options A, C, and D are incorrect procedures.

45) B

- Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed with ear forceps in the emergency department. It is not appropriate to ask the spouse to irrigate the ear. Suggesting the use of antibiotics is inappropriate. Option D is also inappropriate and may cause additional discomfort.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Review about Ear Infection 1-5


Or proceed to the next set of questions:

NCLEX Review about Ear Infection 46-50

Read More

NCLEX Study Course about Delegation and Prioritization Questions 96-100

Welcome to NCLEX Study Course about Delegation and Prioritization Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


96. A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical nurse (LPN) and three nursing assistants on a nursing team. Which of the following clients would the nurse appropriately assign to the LPN?

a) a client with a right leg amputation who requires assistance with a shower
b) a client requiring a bed bath and frequent ambulation with a walker
c) a client who requires frequent temperatures taken
d) a client with a decubitus ulcer that requires a wound irrigation and dressing change

97. A registered nurse (RN) has received the assignment for the day shift. After making initial rounds and checking all the assigned clients, which client will the RN plan to care for first?

a) a postoperative client with chest tubes who has just received pain medication
b) a client scheduled for a chest x-ray at 11:00 AM
c) a client who is scheduled for surgery at 1:00 PM
d) a client who is self-care

98. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

a) a client admitted on the previous shift with a diagnosis of gastroenteritis
b) a client in skeletal traction
c) a client attached to a ventilator
d) a postoperative client preparing for discharge

99. A nurse on the day shift is assigned to care for four clients. Following report from the night shift, which client will the nurse plan to asses first?

a) client scheduled for a cardiac catheterization at 10:00 AM
b) client newly diagnosed with diabetes mellitus who is scheduled for discharge to home
c) client with pulmonary edema who was treated with furosemide (Lasix) at 5:00 AM
d) client scheduled to have an electrocardiogram (ECG) at 9:00 AM

100. A registered nurse (RN) is planning the client assignments for the day. The RN assigns which of the following clients to the nursing assistant?

a) a client who needs range-of-motion exercises every 4 hours
b) a client who needs to be catheterized every 12 hours
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs a dressing change performed every 4 hours





NCLEX Study Course:
Answers and Rationale

96) D

- When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, give a bed bath, ambulate a client with a walker, and take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member.

97) C

- The RN would plan to care for the client who is scheduled for surgery at 1:00 PM first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, often the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is self-care and the client scheduled for an x-ray later in the morning do not have priority needs related to care.

98) C

- Airway is always a high priority, and the nurse would assess the client attached to a ventilator first. The clients described in options A, B, and D have needs that would be identified as intermediate priorities.

99) C

- Airway is always a high priority, and the nurse would assess the client with pulmonary edema who was treated with furosemide at 5:00 am first. The nurse would next assess the client scheduled for the cardiac catheterization, followed by the client scheduled for discharge and the client scheduled for an ECG.

100) A

- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the tasks is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Noninvasive interventions can be assigned to a nursing assistant. Options B, C, and D can be assigned to a licensed practical nurse or another RN because these staff members can perform certain invasive procedures.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Study Course about Delegation and Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Study Course about Delegation and Prioritization Questions (101-105)

Read More

NCLEX Study Course about Delegation and Prioritization Questions 91-95

Welcome to NCLEX Study Course about Delegation and Prioritization Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


91. A nurse is caring for a client who just returned from the recovery room after a tonsillectomy and adenoidectomy. The client is restless and the pulse rate is elevated. The nurse prepares to continue assessing the client, but the client begins to vomit large amounts of bright red blood. The immediate nursing action is to:

a) notify the surgeon
b) continue with the assessment
c) check the client's temperature
d) obtain a flashlight, gauze, and a curved hemostat

92. A postoperative client suddenly develops chest pain and is experiencing dyspnea and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately plans to:

a) ensure that the intravenous (IV) line is patent
b) prepare the client for a perfusion scan
c) administer nasal oxygen
d) place the client on a cardiac monitor

93. An older client with a history of hyperparathyroidism and severe osteoporosis is newly hospitalized. The nurse reviews the plan of care for the client and selects which nursing diagnosis as the priority?

a) risk for injury
b) impaired urinary elimination
c) risk for constipation
d) ineffective health maintenance

94. A client arrives at the nursing unit following internal maxillary fixation (IMF) surgery. The immediate nursing action is to:

a) administer an anti-emetic to prevent vomiting
b) position the client on the side with the head slightly elevated
c) place wire cutters at the bedside
d) connect the nasogastric tube (NGT) to allow intermittent suction

95. A registered nurse is planning the client assignments for the day. Which of the following is the appropriate assignment for the nursing assistant?

a) a client requiring frequent vital signs following a cardiac catheterization
b) a client who requires frequent ambulation
c) a client requiring wound irrigation
d) a client receiving continuous tube feedings






NCLEX Study Course:
Answers and Rationale

91) A

- Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon.

92) C

- Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen.

93) A

- The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history and whether the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a concern but is not the priority.

94) B

- Immediately after IMF surgery, the client is positioned on his side, with the head slightly elevated. The nurse then connects the NG tube to low intermittent suction. Antiemetic medications are administered to prevent vomiting, but this is not the immediate action. Wire cutters should already have been placed at the bedside.

95) B

- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who has had a cardiac catheterization will require specific monitoring in addition to vital signs. Unlicensed personnel do not perform wound irrigations and tube feedings.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Study Course about Delegation and Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Study Course about Delegation and Prioritization Questions (96-100)

Read More

NCLEX Prioritization Questions (86-90)

Welcome to NCLEX Prioritization Questions. Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination.
Good Luck.


86. A nurse employes in a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the nursing assistant?

a) a client who had a below-the-knee amputation
b) a client on a 24-hour urine collection who is on strict bedrest
c) a client scheduled to be transferred to the hospital for coronary artery bypass surgery
d) a client scheduled for transfer to the hospital for an invasive diagnostic procedure

87. The parents of an 18-month-old child arrive at the emergency department with the child. The child is unconscious. The physical examination reveals bruises on the child's upper arms that resemble grip marks, and the nurse suspects child abuse. The first priority of the nurse is to:

a) contact the appropriate state officials to report the abuse case
b) establish a trusting relationship with the parents
c) secure a safe environment for the child
d) stabilize the child's physical condition

88. A nurse is planning care for a client with an obsessive-compulsive disorder. The nurse would assign the highest priority to which of the following nursing interventions?

a) educate the client about self-control techniques
b) establish a trusting nurse-client relationship
c) monitor the client for abnormal behavior
d) encourage participation in daily self-care and unit activities

89. A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility following delegation of the tasks is to:

a) allow each staff member to make judgements when performing the tasks
b) follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task
c) document that the task was complemented
d) assign the tasks that were not completed to the next nursing shift

90. A client who has had abdominal surgery calls the nurse and reports that she felt that "something gave way" in the abdominal incision. The nurse checks the abdominal incision and notes the presence of wound dehiscence. The nurse should take which action first?

a) contact the physician
b) document the findings
c) place the client inlow-fowler's position and instruct the client to lie quietly
d) cover the abdominal wound with a sterile dressing moistened with sterile saline solution



NCLEX Prioritization Questions
Answers and Rationale

86) B

- The nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of nursing practice acts and the job descriptions of the employing agency. A client who had a below-the-knee amputation, a client scheduled to be transferred to the hospital for coronary artery bypass surgery, and a client scheduled for an invasive diagnostic procedure will have physiological as well as psychosocial needs. The nursing assistant is trained to care for a client on bedrest and on a urine collection.

87) D

- In all child abuse cases, the primary concern is the health and safety of the child. Although all of the options are correct, this child is experiencing a medical crisis (unconsciousness); therefore, the first priority is to stabilize the child's condition. Because the child's future health and safety depend on the family, it is critical that the nurse establish a trusting relationship with the parents and collaborate on developing goals that are mutually acceptable. Cases of suspected abuse are reported.

88) B

A trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. The nursing interventions identified in each of the other options may be appropriate but are not of the highest priority.

89) B

- The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

90) C

- Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowler's position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified, and the nurse documents the occurrence and the nursing actions implemented.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Prioritization Questions 91-95

Read More

NCLEX Prioritization Questions 81-85

Welcome to NCLEX Prioritization Questions. Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination.
Good Luck.


81. An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and places a gown on the client to prepare the client for the surgical procedure. Which of the following indicates the appropriate nursing action regarding the client's clothing, which is stained with blood?

a) discard clothing
b) give the clothing to the family member or significant other
c) place the clothing in a paper bag
d) place the clothing in a plastic bag and in a locked cabinet

82. A nurse is assessing a client who has a suspected spinal cord injury. Which of the following is the priority assessment?

a) pupillary response
b) respiratory status
c) mobility
d) pain

83. When delegating a task to a team member, the nurse as the team leader gives authority over the task by:

a) offering suggestions on how to complete the task
b) waiting for the team member to report the results of the completed task
c) completing the task for the team member
d) checking to be sure the task is complete

84. A nurse is assigned to care for a client with coronary artery disease (CAD) who is scheduled fro a cardiac catheterization. Following the catheterization, the priority nursing action is to assess the:

a) catheter insertion site
b) temperature
c) potassium level
d) urine output

85. A nurse in a day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child's needs. The priority consideration in planning activities for the child is to ensure:

a) social interactions with other children in the same age-group
b) safety with activities
c) familiarity with all activities and providing orientation throughout the activities
d) activities that provide verbal stimulation





NCLEX Prioritization Questions
Answers and Rationale

81) C

- All evidence discovered during an examination is recorded. Documentation of evidence includes the bodily location from which the sample was obtained and when or to whom it was delivered. Evidence should be maintained in its original condition. Clothing is stored in a paper bag instead of plastic to prevent decomposition. If clothing needs to be cut off the client, special attention is taken not to destroy evidence inadvertently.

82) B

- All of the assessments in the options would be performed on a suspected spinal cord injury client; however, respiratory status is the priority.

83) B

Authority for task completion is given to the team member by not directing or participating, and allowing the team member to complete the task under her own responsibility. The team member then reports the results to the team leader. Options A, C, and D involve the team leader in task completion.

84) A

- During the post–cardiac catheterization period, priorities of nursing care include frequent monitoring of the blood pressure and pulse. The catheter insertion site is checked frequently for signs of bleeding and swelling. Distal pulses also are assessed. Potassium level, temperature, and urine output should also be monitored but are not the priority of the items identified in the options.

85) B

- Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal communications, and providing familiarity with activities and orientation are also appropriate interventions, the priority is safety.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Prioritization Questions 1-5


Or proceed to the next set of questions:

NCLEX Prioritization Questions 86-90

Read More