NCLEX Questions, NCLEX Trainer Test 10 Questions, NCLEX-PN Questions, Nurselytic

Questions 227

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Extract:


Question 1 of 5

A 45-year-old client with newly diagnosed IDDM (insulin-dependent diabetes mellitus) is being seen by the home health nurse. The physician has placed him on a 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120, respirations 18, temperature 98.2°F (36.8°C). When the client obtains his blood sugar reading, the nurse would expect it to be?

Correct Answer: D

Rationale: hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma

Question 2 of 5

While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?

Correct Answer: D

Rationale: is most effective when communicating with an elderly client

Extract:

A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.


Question 3 of 5

Which of the following nursing actions should take priority during the working stage of their relationship?

Correct Answer: D

Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems

Extract:


Question 4 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the PRIORITY?

Correct Answer: D

Rationale: Ensuring the endotracheal tube is secure is the priority to prevent accidental extubation, which could lead to respiratory failure. Options A, B, and C are important but secondary: checking settings, suctioning, and monitoring saturation follow tube security.

Question 5 of 5

The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?

Correct Answer: B

Rationale: intake and output

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