NCLEX Review About The Aging Eye (11-15)

NCLEX Review About The Aging Eye

11. Which of the following is an effective technique of communicating with a hearing impaired client?

a) speak slowly in a low tone of voice
b) speak slowly in a loud voice
c) speak slowly and try to overemphasize words
d) speak slowly and directly in front of the client

12. Which of the following client statements indicates the need to postpone cataract surgery in the morning?

a) this seasonal allergy should no be a problem
b) the medications instilled into my eyes make my vision blurred
c) I feel nervous with my operation tomorrow
d) I have allergy to certain medications

13. Which of the following is done when performing Weber test?

a) place vibrating tuning fork in front of the opening of the ear
b) place the vibrating tuning fork in the middle of the head
c) place the vibrating tuning fork behind the ear
d) irrigate the ear with cold water and observe movement of the eyes

14. The client has been diagnosed to have Meniere's disease. Which of the following should be included when giving health teachings?

a) limit carbohydrates and proteins in the diet
b) limit salt intake
c) limit fats in the diet
d) drink a lot of fluids

15. The nurse plans care for a client with acute glaucoma who reports severe pain in the eyes and rainbow colors (halos) around lights. Which action should the nurse take first?

a) administer pain medication
b) explain to the client that with reduction in intraocular pressure, pain and other symptoms will subside
c) provide preoperative teachings to the client
d) assess the client's visual status




NCLEX Review About The Aging Eye:
ANSWERS AND RATIONALE

11) D

- speaking slowly allows the client to understand the message. And speaking in fron of the client allows him to read the lip movement of the speaker. Avoid using loud voice pitch. High-pitched voice is more difficult to be understood by hearing-impaired client.

12) A

- seasonal allergy is characterized by sneezing and coughing. These may cause increase in intraocular pressure (IOP) and bleeding after eye surgery.

13) B

- describes weber test, which confirms presence of sensorineural hearing loss like Meniere's disease.

14) B
- meniere's disease is a disorder caused by increased endolymphatic pressure in the inner ear; characterized by vertigo, tinnitus, gradual hearing loss. Low sodium diet is indicated to prevent further accumulation of endolymphatic fluids.

15) A
- pain is the priority problem in a client with glaucoma. Loss of vision in glaucoma is irreversible.


Go to the next page ---> NCLEX Review About The Aging Eye (16-20)  

Or go back to NCLEX Review About The Aging Eye (1-6) to start the test from the beginning.

Read More

NCLEX Review on Delegation and Prioritization Questions (11-15)

NCLEX Review on Delegation and Prioritization Questions

11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?

a) sit the client in a geriatric chair with an activity
b) apply a vest restraint when the client is in a chair
c) apply bilateral wrist restraints when the client is in bed
d) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?

a) perform venipuncture and start an IV line
b) administer oxygen via nasal cannula
c) administer morphine sulfate intravenously
d) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first?

a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath
b) a 16 year old male with ecchymosis, pain, and swelling of the right arm
c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain
d) an 8 year old child who is crying hysterically and reports abdominal pain


14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:

a) assess the child's airway and breathing
b) call 911 and request an ambulance
c) administer subcutaneous epinephrine
d) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is:

a) tell the mother to position the child lying down on her side
b) tell the mother to dial 911 and request an ambulance
c) have the mother give the child a glass of milk
d) instruct the mother on how to administer syrup of ipecac





NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

11) A

promotion of safety and providing diversional activities are priority nursing care for confused elderly clients. Application of restraints should be the last resort. Having a staff member sit with the client at all times is not necessary, unless the client is at risk to injury.

12) B

- administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation.

13) A

- the client with problem of the airway and who has unstable condition should be given highest priority. Priority ABC.

14) A

- the situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC.

15) D

- acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of ipecac is appropriate management in case of acetaminophen overdose or poisoning.




Go to the next page ---> NCLEX Review on Delegation and Prioritization Questions (16-20)  

Or go back to NCLEX Review on Delegation and Prioritization Questions (1-5) to start the test in the beginning


You can also check our main page for the different Compilation of NCLEX Practice Questions

Read More

NCLEX Review about Digestive System Disorders 46-50

NCLEX Review about Digestive System Disorders

46. A client has Sengstaken-Blakemore tube. The nurse, during change-of-shift report should remind the next shift nurse to:

a) keep scissors at bedside
b) avoid instilling fluid into the aspiration port
c) keep tracheostomy tray at bedside
d) deflate the balloon for 15 to 30 minutes every 2 hours

47. The nurse is developing the plan of care for a client receiving continuous ambulatory peritoneal dialysis (CAPD). Which is the priority complication of CAPD to be addressed in the plan of care?

a) bleeding
b) pain
c) outflow problems
d) infection

Situation: Bobby, a 13 year old is being seen in the emergency room for possible appendicitis.

48. An important nursing action to perform when preparing Bobby for an appendectomy is to:

a) administer saline enemas to cleanse the bowels
b) apply heat to reduce pain
c) measure abdominal girth
d) continuously monitor pain

49. Which of the following would indicate that Bobby's appendix has ruptured?

a) diaphoresis
b) anorexia
c) pain at Mc Burney's point
d) relief from pain

50. A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by:

a) administering Tylenol (acetaminophen) for the elevated temperature
b) advising the client to increase oral fluids
c) asking the client when she last had a bowel movement
d) notifying the physician




NCLEX REVIEW ABOUT DIGESTIVE SYSTEM DISORDERS:
ANSWERS AND RATIONALE

46) A

- the nurse should keep scissors readily available at bedside for a client with Sengstaken-Blakemore tube. The scissors will be used to cut the tube in case of airway obstruction due to rupture of the gastric balloon and the esophageal balloon goes up into the pharynx.

47) D

- the most common complication of CAPD is infection (peritonitis). This should be given highest priroty when planning the care of the patient undergoing CAPD.

48) D
- Appendicitis is inflammation of the vermiform appendix (4 inches long) which may lead to edema, necrosis, abscess and rupture, and peritonitis. It is common among teenagers and young adults between 10-30 years old. Higher incidence is observed among males and in societies with diet low in fiber and high in refined carbohydrates.

Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation.

• Initially, appendicitis is manifested by acute and generalized pain of the abdomen that comes in waves.
• During the following 4 hours, pain intensifies and localizes at the right lower quadrant pain at the Mc Burney's point between the anterior iliac crest and umbilicus.
• The pain is aggravated by walking, moving and coughing
• Rebound tenderness (relief of pain on palpation and sudden pain on release of pressure) occurs with abdominal rigidity causing the patient to guard the abdomen.
• Patient tends to lie on back or side with knees bent to relieve pain as extension or internal rotation of the hip increases pain.

Other manifestations of appendicitis include:

• Anorexia, nausea and vomiting
• Chills and fever
• Leukocytosis - 10,000
• elevated neutrophils count

To prevent bowel perforation, it is important to avoid:

• enemas
• laxatives
• applying heat over the abdomen
• food and fluids per orem

49) D

50) D
- the patient's manifestations indicate rupture of the appendix and peritonitis.






Go to the next page ---> NCLEX Review about Digestive System Disorders 51-55  

Or go back to NCLEX Review about Digestive System Disorders 1-5 to start the test from the beginning.

Read More

NCLEX Preparation Course - Critical Thinking Exercises VI (Answers 21-30)

Here are the Questions to NCLEX Preparation Course - Critical Thinking VI (21-30) -->

21) A

- prothrombin time of 25 seconds is prolonged. Normal value is 11 to 16 seconds. Prolonged prothrombin time increases risk of bleeding during and after tonsillectomy. This should be reported to the physician.

22) D

- absence of breath sounds on one side of the chest indicates atelectasis. A client with problem of airway or oxygenation should be given highest priority. ABC is a priority.

23) A

- gingival hyperplasia indicates toxic reaction to anticonvulsant, specifically Dilantin. This needs follow-up. The other choices are normal findings.

24) A

- inform the relative on the nearest health service facility, in case a problem or emergency situation arises.

25) B, C, D, F

- comprise signs and symptoms of Cushing's reflex. The triad components of Cushing's reflex are blood pressure (systolic, diastolic, and pulse pressure), pulse rate and respiratory rate.

26) A

- silvery white scales characterize psoriasis
Choice B - describes scabies
Choice C - describes measles
Choice D - describes herpes zoster

27) B

- mestinon, a cholinergic is best given 20 to 30 minutes before meals to prevent choking in a client with Myasthenia gravis.

28) C

- SIADH is hypersecretion of ADH. The client experiences excessive retention of water. Polyuria is not a manifestation of the disease. Polyuria is a characteristic of diabetes insipidus.

29) A, C, D

-these are nursing interventions after tonsillectomy. Bleeding should be prevented and monitored. It is manifested by frequent swallowing. Ice cream contains milk. This increases viscosity of the saliva that riggers clearing of the throat. Deep breathing is indicated. However, coughing is to be avoided to prevent bleeding.

30) B

- the LVN/LPN is allowed to do wound care and change of wound dressing. Choice A is a task to be done by RN; choices C and D are tasks to be done by the CNA.


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 21-30)

 Here are the Answers to NCLEX Preparation Course - Critical Thinking VI (21-30) -->

21.Prior to tonsillectomy in a child, which of the following laboratory results should be reported to the physician immediately?

a) prothrombin time of 25 seconds
b) hemoglobin of 10 mg/Dl
c) WBC 0f 15,000/cu. mm
d) platelet count of 200,000/cu. mm

22. An emergency department has emergency drill. Which of the following should be given highest priority?

a) a child with bloody face and with fixed, dilated pupils
b) a patient with Glascow coma scale of 13
c) a woman with fracture of legs and swelling
d) a patient with no breath sounds on the affected side of the chest

23. Which among the following patients needs follow-up care?

a) a patient who has status epilepticus with gingival hyperplasia
b) a patient taking rifampicin with red-orange urine
c) a patient taking iron supplement with dark stools
d) a patient taking digoxin whose apical rate decreased from 90 beats per minutes to 80 beats per minute

24. A 76-year old man is to be discharged with his adult child and will stay with him. What will be the nurse's advice?

a) inform the adult child on the nearest health service facility
b) tell the patient that elder abuse is common
c) advice for stay on a long-term healthcare facility
d) inform the patient on availability of hospice care

25. The client had head injury due to vehicular accident. He is experiencing Cushing's reflex. Which of the following would be manifested by the client? Select all that apply

a) increased body temperature
b) decreased respiratory rate
c) increased systolic pressure
d) decreased diastolic pressure
e) restlessness
f) widening of pulse pressure

26. Which of the following is a characteristic lesion of Psoriasis?

a) silvery white scales
b) linear burrows
c) maculo-papular lesions
d) clusters of vesicles

27. Which of the following interventions should be included in the care of the client with myasthenia gravis?

a) start the client's meals with hot soup
b) administer mestinon (pyridostigmine) before feeding
c) place the client in isolation
d) cover the eyes with eye patch

28. Which of the following is not a manifestation of SIADH (Syndrome of Inappropriate ADH)?

a) hyponatremia
b) high specific gravity of urine
c) polyuria
d) hypertension

29. Which of the following should be included in the nursing interventions of the client after tonsillectomy?

a) assess for frequent swallowing
b) include ice cream in the diet
c) apply ice collar on the neck
d) provide non-citrus, non-red, cold beverages
e) encourage to do deep breathing and coughing exercises

30. A registered nurse (RN) on a medical-surgical unit is preparing the assignment for the day shift. The RN is working with a licensed practical (vocational) nurse (LPN/LVN). and a nursing assistant. The RN most appropriately assigns which client to the LPN/LVN?

a) a client who needs preoperative teaching for colectomy
b) a client with a leg wound requiring a dressing change
c) an elderly client who needs assistance with ambulation
d) a client with a 24-hour urine collection process

PREVIOUS [---------------------] NEXT -> CRITICAL THINKING VI (31-40) ->


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Review on Delegation and Prioritization Questions (6-10)

NCLEX Review on Delegation and Prioritization Questions

6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do first?

a) decontaminate the client's clothing
b) decontaminate an open wound on the client's thigh
c) decontaminate the examination room the client is placed in
d) save the client's vomitus for analysis by the radiation safety staff

7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?

a) respiratory status
b) level of consciousness
c) level of pain
d) reflexes and movement of extremities

8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?

a) fiber
b) broccoli
c) yogurt
d) simple carbohydrates

9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent?

a) pain
b) wound infection
c) depression
d) thrombophlebitis


10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?

a) administer pain medication
b) administer IV fluids
c) administer dopamine
d) administer oxygen per nasal cannula




NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

6) B

- decontaminating an open wound is the first priority when caring for a client after a radiologic incident. This minimizes absorption of radiation in the client's body.

7) A

- assessing respiratory status is the first priority when caring for a client in the post-anensthesia care unit. ABC is a priority.

8) B

- broccoli is gas forming. This should be avoided in clients experiencing flatulence.

9) B

- wound infection is the most common complication among obese clients who had undergone surgery. This is due to poor blood supply in the adipose tissues. Therefore, there is decreased oxygen supply and diminished supply of protective cells in the areas.

10) D

- promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest priority by the nurse for a client with dyspnea, chest pain, and syncope.




Go to the next page ---> NCLEX Review on Delegation and Prioritization Questions (11-15)  

Or go back to NCLEX Review on Delegation and Prioritization Questions (1-5) to start the test in the beginning

Read More

NCLEX Review Questions on Cancer (31-35)

NCLEX Review Questions on Cancer

31. Which of these findings in the breast of a patient who is suspected of having breast cancer would support the diagnosis?

a) complaints of dull, achy, pain
b) palpation of a mobile mass
c) presence of an inverted nipple
d) area of discoloration skin

32. A nurse is caring for a client with an internal radiation implant. Which of the following instructions is appropriate?

a) allow the client to go to the bathroom
b) avoid creams and lotions
c) visitors are allowed to stay in the room
d) the client should remain in bed during the entire duration of treatment

33. How often should a female who is above 40 years old, go for cancer detection examination?

a) daily
b) weekly
c) monthly
d) yearly


34. The client is receiving internal radiation therapy. The nurse should

a) remember to give the badge to the next-shift nurse
b) maintain a 30-minute close contact with the patient in a shift
c) wear gloves, mask and gown when entering the client's room
d) instruct relatives no to visit the client during the entire duration of the treatment

35. A nurse is assessing a client with metastatic breast cancer who reports nocturia, weakness, nausea and vomiting. The client's serum electrolytes include potassium 4.2 mEq/L, sodium 135 mEq/L, calcium 7.0 mEq/L, and magnesium 2.0 mEq/L. Based on the assessment findings, the priority action for the nurse is to:

a) start client on fluid restriction
b) administer calcium gluconate
c) increase the client's IV fluids
d) administer Allopurinol




NCLEX Review Questions on Cancer:
ANSWERS AND RATIONALE

31) C

- inversion of nipple is one of the manifestations of breast cancer. A cancerous lesion is non-mobile.

32) D

- the client with internal radiation implant should be on bed rest. This is to prevent dislodgment of the implant.

33) D

- cancer screening for females who are above 40 years of age should be yearly.

34) A

- dosimeter badge is used to measure amount of exposure to radiation. It should be endorsed to the next shift.

35) C

- nocturia, nausea and vomiting cause dehydration. Therefore, the correct nursing action is to increase the client's IV fluids.




Go to the next page ---> NCLEX Review Questions on Cancer (36-40)  

Or go back to NCLEX Review Questions on Cancer(1-3) to start the practice test from the beginning.


Related Topics:

•  Mesothelioma Cancer

• All about Cancer
• Cancer for Nursing Reviewees  

• Online Nursing Classes: NCLEX Practice Test Downloads

Read More