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NCLEX RN Practice Questions Exam Cram
1. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
- A. Diarrhea
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Hyperactive bowel sounds
Correct answer: Metabolic alkalosis
Rationale: In the scenario of persistent vomiting, the child is at risk of developing metabolic alkalosis due to the loss of hydrochloric acid. Vomiting leads to the loss of gastric acid, resulting in an imbalance that causes metabolic alkalosis. Metabolic acidosis is incorrect as it would occur in a child with diarrhea due to the loss of bicarbonate. While diarrhea can sometimes be associated with vomiting, in this case, the primary focus is on the effects of vomiting. Hyperactive bowel sounds are not typically associated with vomiting, making this choice less relevant to the situation described.
2. A client is receiving treatment for delusional behavior. He believes that his neighbor is purposefully poisoning his water system in an attempt to make him sick. Which of the following responses of the nurse is most appropriate?
- A. Did you have the water tested to be sure?
- B. Why do you feel like your neighbor is trying to poison you?
- C. Let's just sit here and watch this television program.
- D. Don't be silly; your neighbor would do no such thing.
Correct answer: Why do you feel like your neighbor is trying to poison you?
Rationale: When a client presents with delusional beliefs, the nurse should avoid arguing with the client and should accept the client's initial need to hold onto the delusions. By asking the client 'Why do you feel like your neighbor is trying to poison you?' the nurse encourages the client to express his beliefs further. This open-ended question allows the client to elaborate on his delusions without feeling judged. It helps build trust between the nurse and the client, which is crucial for therapeutic communication. This approach may eventually lead to the client being more receptive to exploring and addressing his delusions. Choices A, C, and D are incorrect. Choice A may come off as dismissive and does not address the client's underlying beliefs. Choice C is a distraction and does not address the client's concerns. Choice D is confrontational and dismissive of the client's beliefs, which can damage the therapeutic relationship.
3. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?
- A. Use Liquid PaperTM to 'white out' the resolved diagnosis on the care plan
- B. Recopy the care plan without the resolved diagnosis
- C. Write a nursing progress note indicating that the outcome goals have been achieved
- D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Correct answer: Draw a single line through the diagnosis on the care plan and write the nurse's initials and date
Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a 'Date Resolved' column. Using Liquid PaperTM is not a legal way to amend client records as it can obscure the original documentation. Recopying the care plan without the resolved diagnosis can lead to confusion and inaccuracies in the client's record. Writing a nursing progress note indicating that the outcome goals have been achieved is important but should not be the sole method used to communicate the resolution of a nursing diagnosis. Drawing a single line through the resolved diagnosis on the care plan and documenting the nurse's initials and date is the most effective way to communicate the resolution of a nursing diagnosis to the healthcare team.
4. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:
- A. Respiratory protection must be provided to all employees who might be exposed.
- B. Training on respiratory protection must be provided.
- C. Employers must provide personal protective equipment to all employees.
- D. All ED personnel must be trained in decontamination procedures.
Correct answer: All ED personnel must be trained in decontamination procedures.
Rationale: OSHA regulations for hospital employees dealing with hazardous materials or exposed patients require respiratory protection for potentially exposed employees, training on respiratory protection, and the provision of personal protective equipment. However, not all ED personnel are required to be trained in decontamination procedures. While all ED staff should have a basic understanding of hazmat situations, specific training in decontamination procedures is only necessary for those who will be directly involved in the decontamination process. Therefore, the correct answer is that all ED personnel must be trained in decontamination procedures, as this is not a mandatory requirement under OSHA regulations for hospital employees who may encounter hazardous materials or exposed patients.
5. A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?
- A. Is there any history of IV drug use?
- B. Do you use any over-the-counter drugs?
- C. Are you taking corticosteroids for any reason?
- D. Have you recently traveled to a foreign country?
Correct answer: Do you use any over-the-counter drugs?
Rationale: The most appropriate question for the nurse to ask in this scenario is whether the patient uses any over-the-counter drugs. The patient's symptoms, negative serologic testing for viral hepatitis, and sudden onset of symptoms point towards toxic hepatitis, which can be triggered by commonly used over-the-counter medications like acetaminophen (Tylenol). Asking about IV drug use is relevant for viral hepatitis, not toxic hepatitis. Inquiring about recent travel to a foreign country is more pertinent to potential exposure to infectious agents causing viral hepatitis. Corticosteroid use is not typically associated with the symptoms described in the case.
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