NCLEX Exam Practice Question of the Week - 03/02/11
Question: While a client’s wife is visiting she observes the client’s chest drainage system and begins to nervously question the nurse regarding the amount of bloody drainage in the system. What is the best response from the nurse?
1. “Your husband has been really sick; this must be a very difficult time. Let’s sit down and talk about it.”
2. “I have checked all of the equipment and it is working fine; you do not need to worry about it.”
3. “The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding.”
4. “The chest tube is draining the secretions from his chest; it is important for him to deep-breathe frequently.”
1. “Your husband has been really sick; this must be a very difficult time. Let’s sit down and talk about it.”
2. “I have checked all of the equipment and it is working fine; you do not need to worry about it.”
3. “The system is draining collected fluid from around the lungs. The drainage is expected and does not mean that he is bleeding.”
4. “The chest tube is draining the secretions from his chest; it is important for him to deep-breathe frequently.”
Answer: 3.
Rationale: This is important information to explain to the client’s wife regarding the bloody drainage in the chest tube collection system. After the nurse has explained the reason for the drainage, it would be appropriate to sit down and talk with the wife (option 1). Options 2 and 4 do not answer the question or address the wife’s concern.
NCLEX Exam Practice Question of the Week - 03/09/11
Question: A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 11⁄2 weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements?
1. “I need to continue drug therapy for 2 months.”
2. “I can’t shop at the mall for the next 6 months.”
3. “I can return to work if a sputum culture comes back negative.”
4. “I should not be contagious after 2 to 3 weeks of medication therapy.”
1. “I need to continue drug therapy for 2 months.”
2. “I can’t shop at the mall for the next 6 months.”
3. “I can return to work if a sputum culture comes back negative.”
4. “I should not be contagious after 2 to 3 weeks of medication therapy.”
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Answer: 4
Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.
Test-Taking Strategy: Use the process of elimination. Knowing that the medication therapy lasts for at least 6 months helps you eliminate option 1 first. Knowing that three sputum cultures must be negative helps you to eliminate option 3 next. From the remaining options, recalling that the client is not contagious after 2 to 3 weeks of therapy will direct you to option 4. If you had difficulty with this question, review the infectious period of tuberculosis.
Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.
Test-Taking Strategy: Use the process of elimination. Knowing that the medication therapy lasts for at least 6 months helps you eliminate option 1 first. Knowing that three sputum cultures must be negative helps you to eliminate option 3 next. From the remaining options, recalling that the client is not contagious after 2 to 3 weeks of therapy will direct you to option 4. If you had difficulty with this question, review the infectious period of tuberculosis.
NCLEX Exam Practice Question of the Week - 03/16/11
Question: A client with Crohn’s disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client’s health status is related to a major deficiency of:
1. Iron
2. Protein
3. Vitamin C
4. Linoleic acid
1. Iron
2. Protein
3. Vitamin C
4. Linoleic acid
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Answer: 2
Rationale: Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of iron will result in anemia, it will not cause the other adaptations. Vitamin C and linoleic acid are unrelated to these adaptations.
Rationale: Protein deficiency causes a low serum albumin level, which permits fluid shifts from the intravascular to the interstitial compartment, resulting in edema. Decreased protein also causes anemia; protein intake must be increased. Although a deficiency of iron will result in anemia, it will not cause the other adaptations. Vitamin C and linoleic acid are unrelated to these adaptations.
NCLEX Exam Practice Question of the Week - 03/23/11
Question: The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client?Select all that apply.
1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA or FBI.
6. Reassure the client that you are not with the CIA.
1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA or FBI.
6. Reassure the client that you are not with the CIA.
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Answer: 1, 2, 3
Rationale: The client is demonstrating paranoid behavior, which necessitates a matter-of-fact approach that is nonjudgmental and accepting of the client’s statements and shows the nurse’s willingness to listen attentively to the issue. Options 4, 5, and 6 do not help the paranoid client gain trust to talk with the nurse.
Rationale: The client is demonstrating paranoid behavior, which necessitates a matter-of-fact approach that is nonjudgmental and accepting of the client’s statements and shows the nurse’s willingness to listen attentively to the issue. Options 4, 5, and 6 do not help the paranoid client gain trust to talk with the nurse.
NCLEX Exam Practice Question of the Week - 03/30/11
Question: The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instruction(s) should the nurse provide? Select all that apply.
1. Use sunscreen when participating in outdoor activities.
2. Wear a hat, opaque clothing, and sunglasses when in the sun.
3. Avoid sun exposure in the late afternoon and early evening hours.
4. Examine your body monthly for any lesions that may be suspicious.
5. Sunscreen should be applied every 8 hours.
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Answer: 1, 2, 4
Rationale: The client should be instructed to avoid sun exposure between the hours of 10 AM and 4 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.
Test-Taking Strategy: Use the process of elimination and note the strategic words a need for further instructions. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Note the strategic word avoid in option 1 to help direct you to this option. Review client teaching points for the prevention of skin cancer if you had difficulty with this question.
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