NCLEX : General Care
Study concepts, example questions & explanations for NCLEX
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Example Questions
Example Question #31 : General Care
The nurse cares for an immobilized patient on the surgical floor. Which of the following nursing considerations is essential for preventing ulcerations?
Teach client the importance of coughing and deep breathing
Providing a well-balanced diet
Frequently turn and reposition patient while also providing skin care
Use compression stockings or TED hose
Orient client frequently
Frequently turn and reposition patient while also providing skin care
There are many possible complications from immobilization. Decubitus ulcers are one of these complications. It is essential to turn and reposition the patient at least every 2 hours while also maintaining skin integrity with skin care. Many other complications may result from immobilization and each have specific, related nursing considerations. Immobilization can result in desensitization and disorientation, so it is important to orient the client frequently. A well-balanced diet can promote better nutrition to prevent osteoporosis, negative nitrogen balances, and hypercalcemia from being bed-bound. Compression stockings and TED hose are essential to prevent thrombus formation from stagnant blood flow in the lower extremities, which may lead to pulmonary emboli. Coughing and deep breathing is important to prevent the stasis of respiratory secretions, which could lead to hypostatic pneumonia.
Example Question #131 : Procedures And Care
The nurse is caring for a two year old child with chicken-pox. While bathing the patient, the nurse's N-95 (surgical respirator) mask becomes saturated. The nurse should __________.
wait until the patient care is complete and replace the mask
exchange the mask for a new mask immediately
dry the mask with the in-room hairdryer
place a new mask over the old mask
wipe with mask with a clean towel
exchange the mask for a new mask immediately
Varicella (chicken-pox) is a condition requiring airborne precautions. An N-95 mask is considered ineffective when wet and needs to be replaced immediately.
Example Question #1 : Prevention And Risk Management
The nurse is preparing to enter a contact-isolation room where she will preform a bed bath. It is reasonable to expect her gloves to become soiled at some point during the administration of care. While preparing to enter, the nurse __________.
wears a single pair of sterile gloves
wears two pairs of sterile gloves
wears a pair of clean gloves under a pair of sterile gloves
wears two pairs of clean gloves
wears a single pair of clean gloves
wears a single pair of clean gloves
In the interest of infection control, it is best to only wear one pair of gloves at a time. While giving a bed bath, it is not necessary to wear sterile gloves. If the gloves become saturated, remove the gloves, perform hand hygiene, and wear a new pair.
Example Question #31 : General Care
The emergency room nurse cares for a patient reporting pain in the lower back. The client tells the nurse, “I have taken three 500-milligram tablets of acetaminophen every three hours since last night, but the pain hasn’t gone away.” Which of the following clinical manifestations in the patient most concerns the nurse?
alanine transaminase (ALT):
Higher blood pressure
Diarrhea and loose stools
Ringing in the ears
International normalized ratio (INR) of 1.1
alanine transaminase (ALT):
The nurse should be concerned about acetaminophen toxicity, as the recommended daily dose of acetaminophen is 4 grams for adults, and this patient has exceeded this amount. (Three 500-milligram tablets every three hours is equal to 12 grams in a 24-hour period.) Acetaminophen toxicity may manifest with nausea and vomiting in the first 24 hours and right upper quadrant abdominal pain afterwards due to liver damage. Tinnitus, high blood pressure, and diarrhea are not symptoms of acetaminophen poisoning. An international normalized ratio (INR) of 1.1 is within normal limits, but may be trending upwards, as the liver is responsible for producing clotting factors. Liver function tests should always be done when acetaminophen poisoning is suspected; aspartate transaminase (AST) and alanine transaminase (ALT) values above 
Example Question #2 : Prevention And Risk Management
The oncology nurse cares for a patient receiving morphine sulfate 
Blood pressure
Heart rate 65 beats per minute
Respiratory rate 8 breaths per minute
Oxygen saturation 98%
Pain level 7 out of 10
Respiratory rate 8 breaths per minute
The nurse should be aware of potential complications of morphine sulfate, which can cause respiratory depression. Therefore, a respiratory rate of 8 breaths per minute should most concern the nurse (the normal limits are 12-18). The heart rate, blood pressure, and oxygen saturation are within normal limits. A patient on morphine sulfate should complain of pain, and although a pain level of 7 out of 10 requires attention, the respiratory depression takes priority.
Example Question #3 : Prevention And Risk Management
The nurse cares for a patient receiving an intravenous transfusion of gentamicin through an IV catheter in the patient’s left hand. Upon assessment, the nurse notices blanching and swelling at the site of the IV catheter, and the patient states he is feeling 8 out of 10 pain and it is “burning." In what order should the nurse perform the following tasks?
Aspirate the remaining fluid, stop the infusion, discontinue the catheter, and notify the primary care provider.
Discontinue the catheter, aspirate the remaining fluid, stop the infusion, and notify the primary care provider.
Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.
Notify the primary care provider, stop the infusion, aspirate the remaining fluid, and discontinue the catheter.
Stop the infusion, discontinue the catheter, notify the primary care provider, and aspirate the remaining fluid.
Stop the infusion, aspirate the remaining fluid, discontinue the catheter, and notify the primary care provider.
The nurse must recognize these signs and symptoms as potential extravasation, where a vesicant medication such as gentamicin, penicillin, dilantin, or chemotherapy has been given. It is essential to first stop the infusion and remove the insult. The nurse must then aspirate the remaining medication in the catheter to reduce the amount of exposure to the vesicant. The nurse can then remove and discontinue the catheter and notify the primary care provider.
Example Question #5 : Prevention And Risk Management
The nurse counsels patients at a community health fair about the importance of immunizations. Which of the following statements is most accurate concerning immunizations?
“Immunizations provide acquired immunity to some serious infectious diseases.”
“Immunizations will prevent all infectious diseases.”
“Immunizations provide natural immunity to some diseases.”
“Immunizations give your body the antibodies to fight infections.”
“Immunizations are risk-free and recommended by all healthcare providers.”
“Immunizations provide acquired immunity to some serious infectious diseases.”
The nurse should understand the mechanism of action, indications, and risks of immunizations as they do for all medications administered. Immunizations work by passively providing acquired immunity to specific diseases (such as influenza, hepatitis B, and varicella). They imitate a specific pathogen, influencing the patient’s body to produce antibodies that are capable of defending the body if it is exposed to the disease-causing element. The nurse should know that immunizations are specifically made for some diseases, and do not work for all diseases. Immunizations also come with minimal risks, and although they are widely given, are not universally prescribed. Patients should be educated with potential risks; some patients may experience fevers or rashes. Immunizations do not provide natural immunity to diseases; natural immunity is acquired by the patient when they contract a disease via exposure and the body produces its own antibodies. Immunizations do not provide antibodies to each disease.
Example Question #1 : Prevention And Risk Management
The community health nurse provides education about infectious diseases to college students in a dorm. Which of the following statements by the nurse would be appropriate?
“Hepatitis C is transmitted through ingestion of contaminated food and water.”
“Hepatitis B is transmitted through ingestion of contaminated food and water.”
“Hepatitis A is transmitted through ingestion of contaminated food and water.”
Hepatitis D is transmitted through ingestion of contaminated food and water.”
“Hepatitis A is transmitted through infected blood and needles.”
“Hepatitis A is transmitted through ingestion of contaminated food and water.”
Different types of viral hepatitis are transmitted through various routes. Hepatitis A is the only form that is transmitted through the fecal-oral route (contaminated food and water). Hepatitis B and D are transmitted through infected blood/needles as well as sex, and from infected mothers to newborns. Hepatitis C is transmitted through contaminated blood and needles. Recall that hepatitis D is an opportunistic infection, which requires hepatitis B infection.
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