NCLEX Practice Questions Interventions Nursing Prep
NCLEX practice questions Interventions Nursing Prep
Exam (elaborations)
[Solved] NCLEX practice questions Interventions Nursing Prep
23 views 0 purchase
Course
NCLEX practice questions Interventions Nursing Prep
Institution
NCLEX Practice Questions Interventions Nursing Prep
NCLEX practice questions Interventions Nursing Prep
NCLEX practice questions Interventions Nursing Prep Question 1: (see full question) When performing an abdominal assessment,the nurse uses a different order of techniques than with other systems. W hich ofthe following represents this order You s...
nclex practice questions interventions nursing prep
Written for
NCLEX practice questions Interventions Nursing Prep
All documents for this subject (1)
Seller
Follow
solutions
Reviews received
Content preview
Question 1: When performing an abdominal assessment,the nurse uses a
(see full question) different order of techniques than with other systems. Which ofthe
following represents this order
You selected: Inspection, auscultation, percussion, palpation
Correct
Explanation: In an abdominal assessment, start with inspection, then auscultation,
percussion, and palpation. This isthe preferred approach because
palpation and percussion before auscultation may alterthe sounds
heard. (less)
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter
25: Health Assessment, p. 658.
Chapter 25: Health Assessment - Page 658
Question 2: The nurse in post-anesthesia recovery (PAR) is caring for a 27-year-
(see full question) old client following an appendectomy. Twenty minutes after receiving
4 mg of intravenous (IV) morphine for abdominal pain,the client
continues to report abdominal discomfort and requests more
morphine. Which action bythe nurse is best?
You selected: Observethe abdomen for distention and rigidity.
Correct
Explanation: Continued abdominal pain after administration of IV morphine is an
unexpected occurrence and requires further assessment bythe nurse
to rule out peritonitis or internal bleeding by observingthe abdomen
for distention and rigidity. Administration of more morphine could
maskthe cause ofthe abdominal pain and delay diagnosis of a
possible postoperative complication. Applying heat tothe abdomen
would increase blood flow tothe area and potentially increase pain or
internal bleeding. Positioningthe client in a knees-flexed position may
relievethe discomfort, but an assessment is needed before any
, intervention is implemented. (less)
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25:
Health Assessment, p. 658.
Chapter 25: Health Assessment - Page 658
Question 3: The nurse will obtainthe greatest amount of information aboutthe
(see full question) thyroid gland by using which technique of assessment?
You selected: Palpation
Correct
Explanation: The thyroid gland is assessed by palpation, although it is not
normally palpable in some patients.
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter
25: Health Assessment, pp. 647-648.
Chapter 25: Health Assessment - Page 647
Question 4: The nurse is asking admission interview questions andthe client has
(see full question) explainedthe reason for seeking care. Which ofthe following isthe
most appropriate way to documentthe response?
You selected: Client describes shortness of breath and increased sputum
production.
Incorrect
,Correct response: Client states, "I feel winded all ofthe time and yesterday I started
spitting up a lot of phlegm."
Explanation: The client's reason for seeking care should always be stated inthe
client's own words.
Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter
25: Health Assessment, p. 628.
Chapter 25: Health Assessment - Page 628
Question 5: The nurse inthe emergency department observes a client
(see full question) experiencing a generalized tonic–clonic seizure. What isthe priority
intervention forthe nurse to take?
You selected: Assess and maintainthe client's airway.
Correct
Explanation: Risk for aspiration is a concern during a seizure becausethe client
will have copious oral secretions that will need to be suctioned and
allowed to drain out ofthe mouth.the nurse should assessthe client's
airway and maintain it by placingthe client in a side-lying position,
which will allowthe oral secretions to drain from his mouth and not
accumulate in his throat and compromisethe airway. It is
contraindicated to place anything inthe mouth of a person who is
actively convulsing. Reorientingthe client and documentingthe
seizure are important actions afterthe postictal phase, but client
safety isthe priority intervention during a seizure. (less)
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25:
Health Assessment, p. 625.
Chapter 25: Health Assessment - Page 625
, Question 6: The nurse is caring for a client who just informed her that he noticed
(see full question) some blood inthe toilet after a bowel movement.the nurse
assessesthe client's anal area and notes a deep linear separation
inthe skin that extends intothe dermis.the nurse recognizes that this
skin lesion is characteristic of which ofthe following?
You selected: Erosion
Incorrect
Correct response: Fissure
Explanation: A fissure is characterized as a deep linear separation inthe skin that
extends intothe dermis. Erosion is a loss of superficial epidermis; it is
moist and may bleed. An ulcer appears as a loss of epidermis and
dermis and may bleed. Crusts are dried residue (serum, pus, or
blood) onthe skin. (less)
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25:
Health Assessment, p. 641, Table 25-4.
Chapter 25: Health Assessment - Page 641
Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25:
Health Assessment, p. 654, Box 25-5.
Chapter 25: Health Assessment - Page 654
Question 7: The nurse is auscultating an apical pulse on a 39-year-old client
(see full question) admitted with pneumonia. In countingthe apical pulse,the nurse
recognizes which characteristic about heart sounds?
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller solutions. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.49. You're not tied to anything after your purchase.
