NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
Question 2 of 5
The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Correct Answer: B
Rationale: An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and to wear similar hairstyles. Loud music may disturb others in the hospital. Because Crutchfield traction involves the use of skeletal pins, hair dye is not appropriate. The child's request for a darkened room is indicative of a possible problem with depression that may require further evaluation and intervention.
Question 3 of 5
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
Question 4 of 5
A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment should the nurse obtain to manage this problem?
Correct Answer: D
Rationale: The reddened heel results from the pressure of the foot against the mattress. An alternating pressure mattress is effective at minimizing pressure points. The bed cradle will keep the linens off of the client's lower extremities but will not assist with the management of a reddened heel. A draw sheet and trapeze are of general use for this client, but they are not specific for dealing with the reddened heel.
Question 5 of 5
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.