a 75 year old man with a history of hypertension was recently changed to a new antihypertensive drug he reports feeling dizzy at times how would the n

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?

A. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
B. The patient should be directed to walk around the room and his blood pressure assessed after this activity.
C. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

Correct answer: A

Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.

2. The Sims' position is MOST similar to the ________ position.

A. prone
B. lateral
C. supine
D. Fowler's

Correct answer: B

Rationale: The correct answer is 'lateral.' The Sims' position is characterized by the patient lying on their side with the upper knee flexed and the upper arm positioned in front of the body. This is similar to the lateral position where the patient is also lying on their side. The prone position (choice A) is when the patient lies face down, the supine position (choice C) is when the patient lies face up, and Fowler's position (choice D) is a seated position with the head of the bed elevated at a 45-90 degree angle. Therefore, the lateral position is the most similar to the Sims' position as both involve the patient lying on their side.

3. During a class on religion and spirituality, the nurse is asked to define spirituality. Which statement by the nurse best describes spirituality?

A. "Is a personal search to discover a supreme being."?
B. "Is an organized system of beliefs concerning the cause, nature, and purpose of the universe."?
C. "Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife."?
D. "Focuses on a connection with something bigger than oneself and a belief in transcendence."?

Correct answer: D

Rationale: Spirituality is a broad term that focuses on a connection with something greater than oneself and a belief in transcendence. It is a personal journey that arises from unique life experiences and the individual's quest to find purpose and meaning in life. The correct answer emphasizes the essence of spirituality, which involves seeking a connection with a higher power and believing in transcendence. Choices A, B, and C, on the other hand, define aspects of religion rather than spirituality. Choice A refers to a personal search for a supreme being, which is more aligned with religious beliefs. Choice B describes an organized system of beliefs about the universe, typically associated with religion. Choice C pertains to beliefs about existence after death, such as reincarnation or the afterlife, which are often religious concepts. Therefore, the best description of spirituality is focusing on a connection with something beyond oneself and a belief in transcendence.

4. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

A. Inform the client that he may experience tingling sensations.
B. Connect the TENS unit before the client goes to bed for the night.
C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

5. Where is the Loop of Henle located in the body?

A. Liver
B. Kidney
C. Heart
D. Ear

Correct answer: B

Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.