application a nurse is caring for a patient admitted in the emergency room for an ischemic stroke with marked functional deficits the physician is c
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?

Correct answer: D

Rationale: The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.

2. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:

Correct answer: A

Rationale: After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.

3. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?

Correct answer: B

Rationale: The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.

4. Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy?

Correct answer: B

Rationale: To evaluate treatment effectiveness for a patient with hepatic encephalopathy, requesting the patient to walk with eyes closed is crucial. This test assesses the patient's balance, gait, and coordination, which can be impaired in hepatic encephalopathy due to altered mental status and brain function. Walking with eyes closed challenges the patient's sensory input and proprioception, providing valuable information on improvement or deterioration in neurological function. Asking the patient to extend both arms forward is used to check for asterixis, a sign often seen in hepatic encephalopathy, but it is not specific for evaluating treatment effectiveness. Performing the Valsalva maneuver is unrelated to assessing hepatic encephalopathy and is more commonly used in cardiac evaluations. Observing the patient's breathing pattern may be important in other conditions but is not directly relevant to evaluating treatment effectiveness for hepatic encephalopathy.

5. While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?

Correct answer: B

Rationale: When addressing obesity in adolescents, it is crucial to consider that poor body image is a common behavior associated with obesity. As adolescents gain weight, they may experience a decrease in self-esteem and a negative perception of their body. This can contribute to a cycle of unhealthy behaviors and impact their overall well-being. The other choices are less commonly associated with obesity in adolescents. Sexual promiscuity may be influenced by various factors unrelated to obesity, dropping out of school is more often linked to academic challenges or social issues, and drug experimentation can stem from a range of influences but is not directly correlated with obesity.

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