KAPLAN NCLEX EXAM 200 QUESTION AND ANSWERS WITH EXPLANATIONS VERSION 5

KAPLAN NCLEX EXAM 200 QUESTION AND ANSWERS WITH EXPLANATIONS VERSION 5 1. The nurse returns to the nurse’s station after making client rounds and finds four phone messages. Which of the following messages should the nurse return FIRST? 1. A client with hepatitis A who states, “My arms and legs are itching.” 2. A client with a cast on the right leg who states, “I have a funny feeling in my right leg.” 3. A client with osteomyelitis of the spine who states, “I am so nauseous that I can’t eat.” 4. A client with arthritis who states, “I am having trouble sleeping at night.” Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct—may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority 2. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker. Which of the following statements by the nurse is BEST? 1. “Sit in a low chair for ease in getting up to use the walker.” 2. “Make sure rubber caps are in place on all four legs of the walker.” 3. “You will begin weight-bearing on the affected hip soon.” 4. “Practice tying your own shoes before you begin ambulating.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct—intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks 3. A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made. It would be MOST important for the nurse to take which of the following actions? 1. Start an IV of terbutaline (Brethine) and monitor the patient’s vital signs closely. 2. Prepare the patient for an immediate cesarean section. 3. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved. 4. Monitor the patient’s length and duration of contractions. Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct—implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed 4. Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia? 1. Heart rate of 148 beats per minute. 2. Bluish discoloration of the skin. 3. Bluish discoloration around the mouth. 4. Difficulty swallowing. Strategy: Determine how each answer choice relates to epiglottitis. (1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis 5. After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST? 1. Limit visiting hours to promote optimal rest. 2. Arrange for clergy to visit with the client and family as requested. 3. Arrange for a psychologist to visit with the family. 4. Arrange for the family to meet with a social worker to discuss financial aid. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct—would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation