the nurse is caring for a post surgical client at risk for developing deep vein thrombosis which intervention is an effective preventive measure a pla the nurse is caring for a post surgical client at risk for developing deep vein thrombosis which intervention is an effective preventive measure a pla
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NCLEX RN Practice Questions Exam Cram

1. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Correct answer: Encourage range of motion and ambulation

Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.

2. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

Correct answer: Encourage the client to call the clinic nurse or healthcare provider if any questions arise.

Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or healthcare provider if any questions arise. This direct communication allows for personalized assistance and clarification tailored to the client's specific concerns. Providing Internet sites (Choice A) may lead to unreliable information, and a drug reference book (Choice B) may not address individualized questions. While the written instructions may contain information (Choice C), they may not cover all potential queries the client might have, making direct contact with the healthcare provider the most appropriate option.

3. Which pathologic condition is described as 'increased intraocular pressure of the eye'?

Correct answer: D: Glaucoma

Rationale: The correct answer is Glaucoma. Glaucoma is a condition characterized by increased intraocular pressure in the eye, which can lead to optic nerve damage, vision loss, and blindness if left untreated. Detached Retina (A), Fovea Centralis (B), and Presbyopia (C) are not conditions associated with increased intraocular pressure like Glaucoma. Detached Retina is a separation of the retina from its underlying tissue, Fovea Centralis is a part of the retina responsible for sharp central vision, and Presbyopia is an age-related condition affecting near vision due to the loss of flexibility in the eye's lens.

4. A client at a local university claims to be the president of the university. Which type of delusion is the client displaying?

Correct answer: B: Grandiose

Rationale: The correct answer is 'Grandiose.' This type of delusion involves an exaggerated sense of self-importance, where the individual believes they are a prominent figure or possess special abilities. In this scenario, the client claiming to be the president of the university is displaying grandiose delusions. Somatic delusions relate to bodily functions or sensations, which are not present in this case. Erotomanic delusions involve the fixed belief that another person is in love with the individual, which is not applicable here. Persecutory delusions involve the belief that one is being targeted or conspired against, which is also not demonstrated in the given situation.

5. 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:

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.

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