KAPLAN NCLEX EXAM 150 QUESTION AND ANSWERS WITH EXPLANATIONS VERSION 4

KAPLAN NCLEX EXAM 150 QUESTION AND ANSWERS WITH EXPLANATIONS VERSION 4 1. The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask? 1. “Did you have anything to eat or drink before you came in today?” 2. “Have you had any headaches since your last treatment?” 3. “Who came with you to the hospital today?” 4. “Have you had much memory loss since you began your treatments?” Strategy: Determine how each answer choice relates to ECT. (1) correct–client given general anesthesia for ECT; NPO after midnight (2) not relevant to ECT (3) not most important (4) memory loss is an expected outcome 2. A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective? 1. Lemonade. 2. Prune juice. 3. Milk. 4. Orange juice. Strategy: “Teaching was effective” indicates you are looking for a true statement. (1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk, carbonated beverages (2) correct–promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon (3) excessive amounts of milk promotes alkaline urine (4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and carbonated beverages 3. The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning? 1. Referral to a social service agency for assistance with housing. 2. Referral to an aftercare center in the community. 3. Participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. A prescription for an antidepressant medication. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be of some help, but will not directly provide support necessary to maintain sobriety (2) may be of some help, but will not directly provide support necessary to maintain sobriety (3) correct–self-help groups have greatest success rate as a sustained support system in the community (4) unnecessary 4. A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST? 1. “A booster shot is required yearly.” 2. “Additional injections are given at one and six months.” 3. “Repeat doses are given at two and four months.” 4. “Revaccination is not required.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) yearly doses are given for flu shots, not for hepatitis B vaccine (2) correct–hepatitis B vaccine is repeated at one and six months (3) schedule for infant immunizations for OPV and DPT (4) inaccurate 5. The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST? 1. Change the IV tubing each time a new IV solution is hung. 2. Cleanse the IV site with an alcohol swab using long strokes. 3. Limit manipulation of the cannula at the IV insertion site. 4. Adjust the drop rate to keep the total volume of IV fluids on schedule. Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. “BEST” indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, changed every 48–72 hrs (2) should move swab in a circular motion outward (3) correct–will prevent dislodgment of needle (4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids 6. The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST? 1. Send the staff member home. 2. Assess the staff member’s compliance with standard precautions. 3. Assign the staff member only to clients with chronic diseases. 4. Re-assign the staff member to clean the supply closet. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3–7 days (2) restrict from patient contact and the patient’s environment (3) restrict from patient contact and the patient’s environment (4) cannot work 7. The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program? 1. Monitor the client’s ability to complete her activities of daily living (ADL). 2. Assess the client’s levels of pain and correlate it with her response to analgesia. 3. Observe the client’s behavior at regular intervals to obtain baseline information related to her screaming. 4. Ask the client why she is screaming and document it on her nursing assessment record. Strategy: Determine what is being assessed in each answer choice and how it relates to screaming. (1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program (2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program (3) correct–to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors (4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic