KAPLAN NCLEX 200+ QUESTION AND CORRECT ANSWERS WITH EXPLANATIONS VERSION 6

1. The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans would be a priority to meet the needs of this father? 1. Encourage the father to call his wife after work. 2. Instruct the father about visiting policy and suggest AM visitation. 3. Adjust visiting hours to meet the new parents’ needs. 4. Present a change of visiting hours to the appropriate hospital committee. Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? (1) inflexible (2) inflexible (3) correct–role of nurse is to be a family and client advocate; this provides individualized care not a priority, although it may be an appropriate long-range goal (4) not a priority, although it may be an appropriate long-range goal 2. The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST? 1. “After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.” 2. “I saw my coworker downtown after work. S/he was acting really strange, like s/he didn’t even recognize me.” 3. “I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.” 4. “My coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.” Strategy: All answers are assessment. Determine how each relates to the situation. (1) correct—report objective information that can be verified; clues to possible substance abuse by staff include memory lapses, frequent absences from the floor, increased number of clients reporting unrelieved pain or insomnia (2) subjective observation (3) subjective observation (4) “hanging around with drug dealers” is subjective 3. A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders? 1. Theophylline (Somophyllin) 0.7 mg/kg/hr IV. 2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd. 3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid. 4. Propranolol hydrochloride (Inderal) 40 mg PO bid. Strategy: You are looking for an incorrect medication. Think about the action of each drug. (1) drug of choice for acute asthma (2) broad spectrum antibiotic, not contraindicated (3) blocks parasympathetic stimulation and decreases mucus; used with asthma (4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction 4. A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, “I guess we just don’t get along.” Which of the following responses by the nurse is MOST appropriate? 1. “Your wife seems to be upset by the situation.” 2. “Perhaps you should both go home now.” 3. “Try to think about what precipitated her crying.” 4. “The situation is difficult for both of you.” Strategy: Remember therapeutic communication. (1) nontherapeutic; emphasis is placed on wife, not the situation (2) nontherapeutic; closes off communication (3) nontherapeutic; appears to blame the husband for precipitating the wife’s behavior, would cause him to react defensively (4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife 5. A client on chemotherapy has a WBC count of 1,200/mm3 . Which of the following nursing actions should the nurse take FIRST? 1. Check temperature q4h. 2. Monitor urine output. 3. Assess for bleeding gums. 4. Obtain an order for blood cultures. Strategy: Determine how each assessment relates to a low white count. (1) correct—important to monitor for infection which would be evidenced by an elevated temperature in a client with a low WBC (2) important because of problems of increased uric acid excretion from chemotherapeutic drugs but should not be done first (3) would be associated with a low platelet count (4) would be done if the temperature were elevated to determine the type of organism involved 6. A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a “dry labor.” Which of the following responses by the nurse would be MOST appropriate? 1. “The amniotic fluid provides only minimal lubrication for the labor process.” 2. “The amniotic sac may impede the progress of labor and is often ruptured artificially.” 3. “Labor is only slightly more difficult with early rupture of the amniotic sac.” 4. “Because there is limited amniotic fluid, additional fluids will be supplied.” Strategy: “MOST” indicates there may be more than one answer that you like. (1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal development, facilitates symmetrical growth, maintains constant body temperature, is a source of oral fluids, and collects wastes (2) correct—sometimes done to assist or induce labor (3) does not make labor more difficult (4) no additional fluids will be supplied 7. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed? 1. Redness or inflammation of the tissue. 2. Mottling or graying of the tissue. 3. The client states that she feels a burning and tingling sensation in the area. 4. The client state that she feels a numbness and a cold sensation in the area. Strategy: “MOST concerned” indicates a complication. (1) indicates inflammation (2) correct—site should be observed every five minutes for signs of tissue intolerance, including blanching, mottling, or graying (3) usually indicates ischemia or sensorineural impairment (4) expected outcome of numbness, which would lead to decreased pain perception 8. The nurse is caring for a client with a complete heart block. The nurse should question which of the following orders? 1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute. 2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for sustained bradycardia below 30.

KAPLAN NCLEX 200+ QUESTION AND CORRECT ANSWERS WITH EXPLANATIONS VERSION 6