Tuesday, February 24, 2009

NCLEX PRACTICE Q & A 001 WITH RATIONALE

1.) A client with a TURP returns from surgery with an indwelling catheter attached to a drainage bag and continuous bladder irrigation. Two hours after surgery, he complains of bladder spasms. The nurse should give priority to:

A.) Offering him fluids by mouth

B.) Administering the prescribed analgesic

C.) Assessing catheter patency

D.) Massaging the symphysis pubis

2.) Which of the following instructions should be included in the discharge teaching of a client with mandibular wires?

A.) Swallow saliva that collects in your mouth to help keep your mouth from becoming dry.

B.) Move your lips as little as possible

C.) Clean wires with saline-moistened cotton swabs

D.) Keep wire cutters with you at all times

3.) Following a cholescystectomy, the client’s diet should be:

A.) Low residue

B.) Low fat

C.) Low protein

D.) Low sodium

4.) Obstructive biliary tract disease and gallbladder disease are often associated with:

A.) Hypertension

B.) Diabetes

C.) Obesity

D.) Infertility

5.) Which of the following is a sign of osteomyelitis?

A.) Fever and tachycardia

B.) Nausea and dehydration

C.) Erythema distal to the injury site

D.) Fatigue and lethargy

6.) A client with renal disease should be monitored frequently for complications of her illness. Which of the following is a complication of renal disease?

A.) Hepatitis

B.) Cardiomegaly

C.) Osteoporosis

D.) Hypocholesterolemia


7.) A client is being monitored for cardiac arrhythmias. While monitoring client, the nurse recognizes bizarre QRS complexes that are lacking a P wave. The nurse would recognize these beats as:

A.) Atrial tachycardia

B.) Premature ventricular beats

C.) Signs of heart block

D.) Premature atrial beats

8.) A client with diagnosis of trichimonas is treated with Metronidazole (Flagyl). Which instruction should the nurse give the client taking Flagyl?

A.) Take the medicine with juice.

B.) Do not drink alcohol while taking Flagyl.

C.) Return to the clinic for regular eye exams.

D.) Allow 6 weeks for the drug to be effective.

9.) The nurse initiates cardioversion on the client in ventricular fibrillation. Cardioversion is synchronized with which part of the ECG complex?

A.) T-wave

B.) S-T segment

C.) Q-T interval

D.) QRS complex

10.) An elderly client is experiencing kyphosis. The nurse can help alleviate the pain associated with kyphosis by:

A.) Administering a heating pad to the client’s back

B.) Telling the client about relaxation exercises

C.) Administering narcotics routinely

D.) Applying ice to the client’s extremities

11.) A client is scheduled for surgery and has an order for Promethezine (Phenergan) to be administered with Meperidine (Demerol). The nurse is aware that the Promethezine is administered to:

A.) Dry secretions

B.) Decrease nausea

C.) Provide pain relief

D.) Prevent Infections

RATIONALE:

1.) Answer: C

-A primary cause of bladder spasms is an obstructed catheter. Continuous irrigation will help prevent clot formation, but kinks in the catheter will prevent outflow. Offering oral fluids is of no help. If the catheter is obstructed, administration of an analgesic will offer little relief and mask symptoms. Massaging the symphysis can increase the pain.

2.) Answer: D

-A client with mandibular wires should keep a pair of wire cutters with her at all times. Saliva can be swallowed or spit out of the mouth, moving the lips will not interfere with the wiring, and cleaning the wires with saline is not necessary.

3.) Answer: B

-Following a cholecystectomy, a client will want to eat a diet low in fat because fat can continue to cause discomfort. He does not, however, have to eliminate it from his diet completely. A low-residue diet is not required, nor are low-protein or low-sodium diets.

4.) Answer: C

-Obesity is often associated with gallbladder disease. The other answers are not associated with it.

5.) Answer: A

-Osteomyelitis is an infection of the bone. The signs are fever, redness at the site, pain, and signs of cardiac adjustment such as tachycardia. Nausea and dehydration are not associated with it. Erythema or redness will be at the site and proximal to the site. Fatigue and lethargy are not directly associated with it.

6.) Answer: B

-A complication of renal disease is anemia due to a lack of erythropoietin. This leads to chronic hypoxia and heart enlargement. The others are not associated with renal disease.

7.) Answer: B

-The description in the stem is of a PVC. The others are incorrect assessments.

8.) Answer: B

-Clients taking Flagyl should not drink alcohol. If alcohol is consumed, the client will experience nausea and vomiting. Answer A is incorrect because the client can take the medication with juice. Answer C is incorrect because there is no need for eye exams. Answer D is incorrect because the medication is taken for 10 days.

9.) Answer: D

-The cardioversion should be synchronized to the QRS complex to prevent severe dysrythmias. The others are incorrect timing.

10.) Answer: A

-Kyphosis is hump back or a forward curvature of the back. This frequently causes severe muscle spasms. Telling the client about relaxation exercises will not help. Administering a narcotic would help but will not be ordered routinely, and applying ice is not the best option.

11.) Answer: B

-Phenergan is an antiemetic. When given with Demerol, it helps to decrease the nausea, a side effect of that medication. It is not used to dry secretions, provide pain relief, or prevent infection.

1 comment:

  1. thanks for these post. I learned something! good job...

    ReplyDelete