NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care?
Correct Answer: A,C,D,E
Rationale: The nurse provides supportive care by encouraging the client to participate in care and to identify coping strategies. Counseling needs to continue after the infant is born. Communication with family members is important but not when they are supporting the addiction. It is not appropriate to suggest adoption.
Question 2 of 5
A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?
Correct Answer: C
Rationale: Triamterene is a potassium-retaining diuretic, and the client should avoid foods that are high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, oranges, mangoes, cantaloupe, strawberries, nectarines, papayas, and dried prunes.
Question 3 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 4 of 5
A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?
Correct Answer: C
Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the primary health care provider.
Question 5 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.