NCLEX Prep Questions with complete solutions.A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that t...
a client with a history of polysubstance abuse is admitted to the facility he complains of nausea and vomiting 24 hours after admission the nurse who as
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NCLEX Prep Questions with complete
solutions.
A client with a history of polysubstance abuse is admitted to the facility. He complains of
nausea and vomiting 24 hours after admission. The nurse who assesses the client
notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client
is going through withdrawal from which substance?
a) Alcohol
b) Cannabis
c) Cocaine
d) Opioids - Answer d) Opioids
Reason: Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal.
A client with alcohol withdrawal would show elevated vital signs. There is no real
withdrawal from cannabis. Symptoms of cocaine withdrawal include depression,
anxiety, and agitation.
The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally
twice a day for:
a) Insomnia.
b) Headache.
c) Anxiety.
d) Orthostatic hypotension. - Answer d) Orthostatic hypotension.
Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal)
therapy. The nurse should monitor the client's blood pressure sitting and standing and
teach the client interventions to manage this adverse effect to prevent risk of injury.
Although insomnia, headache, and anxiety are possible adverse effects of risperidone
therapy, they are of less immediate concern than orthostatic hypotension.
A client who is 32 weeks pregnant presents to the emergency department with bright
red bleeding and no abdominal pain. A nurse should first:
a) perform a pelvic examination.
b) assess the client's blood pressure.
c) assess the fetal heart rate.
d) order a stat hemoglobin and hematocrit. - Answer c) assess the fetal heart rate.
Reason: The nurse should assess the fetal heart rate for distress or viability. She
shouldn't attempt to perform a pelvic examination because of the possibility of placenta
previa, which presents as bright red bleeding without abdominal pain. The nurse should
assess the client's blood pressure after attempting to hear fetal heart tones. Ordering a
hemoglobin and hematocrit is a physician intervention, not a nursing intervention.
, NCLEX Prep Questions with complete
solutions.
A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are
occurring every 2 minutes. She's irritable and in considerable pain. What type of
breathing should the nurse instruct the woman to use during the peak of a contraction?
a) Deep breathing
b) Shallow chest breathing
c) Deep, cleansing breaths
d) Chest panting - Answer b) Shallow chest breathing
Reason: Shallow chest breathing is used during the peak of a contraction during the
transitional phase of labor. Deep breathing can cause a woman to hyperventilate and
feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing
breath taken at the beginning and end of each breathing exercise can help prevent
hyperventilation. Chest panting may be used to prevent a woman from pushing before
the cervix is fully dilated.
After being treated with heparin therapy for thrombophlebitis, a multiparous client who
delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the
client about the medication and possible effects, which of the following client statements
indicates successful teaching?
a) "I can take two aspirin if I get uterine cramps."
b) "Protamine sulfate should be available if I need it."
c) "I should use a soft toothbrush to brush my teeth."
d) "I can drink an occasional glass of wine if I desire." - Answer c) "I should use a soft
toothbrush to brush my teeth."
Reason: Successful teaching is demonstrated when the client says, "I should use a soft
toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft
toothbrush should be used to minimize this adverse effect. Use of aspirin and other
nonsteroidal anti-inflammatory medications should be avoided because of the increased
risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy.
Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral
anticoagulants and should be avoided.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes
into labor at 38 weeks and gives birth. Which priority intervention should be included in
the care plan for the neonate during his first 24 hours?
a) Administer insulin subcutaneously.
b) Administer a bolus of glucose I.V.
c) Provide frequent early feedings with formula.
d) Avoid oral feedings. - Answer c) Provide frequent early feedings with formula.
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