Nclex study-Cris
100-Sickle-cell crisis. Which of the following nursing actions should the nurse
take FIRST? - correct answer ✔Begin an IV with normal saline. Dehydration
perpetuates cell sickling; intake should be at least 200 cc/hour
A client with a pacemaker calls to report that he just had an episode of
dizziness and shortness of breath. - correct answer ✔The Rn should ask
"What is your pulse?"
client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns
the client operates a horse ranch - correct answer ✔Carry a cell phone and
dressings and tape.
nurse should assign a nursing assistant to care for - correct answer ✔A
client diagnosed with a CVA 2 weeks ago requiring assistance ambulating.
The nurse counsels a client diagnosed with degenerative joint disease -
correct answer ✔"Place your joints in their functional position."maintains
mobility of joints
The nurse prepares a client for a skin biopsy. Which of the following
statements, if made by the client, should the nurse report to the physician? -
correct answer ✔"I have been taking aspirin for my aching joints."aspirin can
increase the risk for bleeding and should be reported
A man hospitalized for alcohol abuse comes to the nurses' station and asks
the nurse if he can go to the cafeteria to get something to eat. When told that
his privileges do not include visiting the cafeteria, the patient becomes
verbally abusive. - correct answer ✔Calmly but firmly escort the patient to his
room. Limit-setting, ensures safety; patient with substance abuse needs
,consistent, undivided staff approach, clearly defined expectations, as well as
limit-setting; avoid threats and promises
Which of the following patients should the nurse see FIRST? - correct answer
✔A patient complaining of chest pain with asymmetrical chest movement
CORRECT— indicates flail; monitor for shock, give humidified oxygen,
manage pain, monitor ABGs noted.
Two days after insertion, the chest tube is accidentally pulled out of the pleural
space - correct answer ✔Apply pressure with a dressing that is tented on
one side. ) CORRECT— decreases chance that atmospheric air will enter
pleural space and allows for escape of pleural air
90-patient hospitalized for a head injury. The client is receiving 0.9% sodium
chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse
notes the patient's urinary output is 1,000 cc in 3 hours. - correct answer
✔Measure the urine specific gravity. CORRECT— low specific gravity (1.001
and 1.005) is characteristic of diabetes insipidus; head injury causes
interference with production or release of ADH; record I and O, urine specific
gravity, and daily weight; ensure client's intake of fluid and administer DDAVP
Which of the following clients should the nurse see FIRST? - correct answer
✔An unconscious client with left-sided tracheal shift from midlineCORRECT—
first sign of a tension pneumothorax; airway and breathing take priorit
Which of the following messages should the nurse respond to FIRST? -
correct answer ✔The mother of a 15-year-old reports her son is threatening
to jump off a bridge and has access to a gun.
CORRECT— using Maslow Hierarchy of Needs theory to prioritize,
physiological issues take priority over psychological issues; patient is at risk
for self harm and must be seen first; observe for safety
, Which of the following clients should the nurse see FIRST? - correct answer
✔A client 3 days post right knee replacement complaining of right calf pain
with movement.(2) CORRECT—assessment for possible DVT should be
performed and reported to the physician immediately
Which of the following clients should the nurse see FIRST? - correct answer
✔A 55-year-old receiving 5-fluorouracil (5-FU).) CORRECT— because many
chemotherapy agents may result in neutropenia, clients receiving drugs are
more susceptible to infection, less likely to be able to fight the infection;
symptomatic clients require immediate evaluation and treatment
Responding to the scene of a motor vehicle collision (MVC), which of the
following clients should the nurse see FIRST? - correct answer ✔An
unconscious client with a crushing chest wound.2) CORRECT— clients with
crushing chest wounds are at risk for a number of injuries that may
compromise airway, breathing, circulation, cervical spine, and the nervous
system; immediate evaluation is required
Which of the following patients should the nurse see FIRST? - correct answer
✔A 9-year-old who has used a weapon toward his mother and caused
physical harm to others.A 9-year-old who has used a weapon toward his
mother and caused physical harm to others.
Which of the following patients should the nurse see FIRST? - correct answer
✔A patient who took 10 methylphenidate (Ritalin) and has a blood pressure of
160/100.CORRECT— most unstable patient; assess for restlessness, dilated
pupils, tremors, and seizures. Stimulant like amphetamines, improves
alertesness and concentration.
Which of the following patients should the nurse see FIRST? - correct answer
✔A 35-year-old who had a hysterosalpingogram is experiencing tachycardia,
and has a generalized rash.(2) CORRECT— x-ray of the cervix, uterus, and
fallopian tubes performed after the injection of a contrast medium; assess for
100-Sickle-cell crisis. Which of the following nursing actions should the nurse
take FIRST? - correct answer ✔Begin an IV with normal saline. Dehydration
perpetuates cell sickling; intake should be at least 200 cc/hour
A client with a pacemaker calls to report that he just had an episode of
dizziness and shortness of breath. - correct answer ✔The Rn should ask
"What is your pulse?"
client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns
the client operates a horse ranch - correct answer ✔Carry a cell phone and
dressings and tape.
nurse should assign a nursing assistant to care for - correct answer ✔A
client diagnosed with a CVA 2 weeks ago requiring assistance ambulating.
The nurse counsels a client diagnosed with degenerative joint disease -
correct answer ✔"Place your joints in their functional position."maintains
mobility of joints
The nurse prepares a client for a skin biopsy. Which of the following
statements, if made by the client, should the nurse report to the physician? -
correct answer ✔"I have been taking aspirin for my aching joints."aspirin can
increase the risk for bleeding and should be reported
A man hospitalized for alcohol abuse comes to the nurses' station and asks
the nurse if he can go to the cafeteria to get something to eat. When told that
his privileges do not include visiting the cafeteria, the patient becomes
verbally abusive. - correct answer ✔Calmly but firmly escort the patient to his
room. Limit-setting, ensures safety; patient with substance abuse needs
,consistent, undivided staff approach, clearly defined expectations, as well as
limit-setting; avoid threats and promises
Which of the following patients should the nurse see FIRST? - correct answer
✔A patient complaining of chest pain with asymmetrical chest movement
CORRECT— indicates flail; monitor for shock, give humidified oxygen,
manage pain, monitor ABGs noted.
Two days after insertion, the chest tube is accidentally pulled out of the pleural
space - correct answer ✔Apply pressure with a dressing that is tented on
one side. ) CORRECT— decreases chance that atmospheric air will enter
pleural space and allows for escape of pleural air
90-patient hospitalized for a head injury. The client is receiving 0.9% sodium
chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse
notes the patient's urinary output is 1,000 cc in 3 hours. - correct answer
✔Measure the urine specific gravity. CORRECT— low specific gravity (1.001
and 1.005) is characteristic of diabetes insipidus; head injury causes
interference with production or release of ADH; record I and O, urine specific
gravity, and daily weight; ensure client's intake of fluid and administer DDAVP
Which of the following clients should the nurse see FIRST? - correct answer
✔An unconscious client with left-sided tracheal shift from midlineCORRECT—
first sign of a tension pneumothorax; airway and breathing take priorit
Which of the following messages should the nurse respond to FIRST? -
correct answer ✔The mother of a 15-year-old reports her son is threatening
to jump off a bridge and has access to a gun.
CORRECT— using Maslow Hierarchy of Needs theory to prioritize,
physiological issues take priority over psychological issues; patient is at risk
for self harm and must be seen first; observe for safety
, Which of the following clients should the nurse see FIRST? - correct answer
✔A client 3 days post right knee replacement complaining of right calf pain
with movement.(2) CORRECT—assessment for possible DVT should be
performed and reported to the physician immediately
Which of the following clients should the nurse see FIRST? - correct answer
✔A 55-year-old receiving 5-fluorouracil (5-FU).) CORRECT— because many
chemotherapy agents may result in neutropenia, clients receiving drugs are
more susceptible to infection, less likely to be able to fight the infection;
symptomatic clients require immediate evaluation and treatment
Responding to the scene of a motor vehicle collision (MVC), which of the
following clients should the nurse see FIRST? - correct answer ✔An
unconscious client with a crushing chest wound.2) CORRECT— clients with
crushing chest wounds are at risk for a number of injuries that may
compromise airway, breathing, circulation, cervical spine, and the nervous
system; immediate evaluation is required
Which of the following patients should the nurse see FIRST? - correct answer
✔A 9-year-old who has used a weapon toward his mother and caused
physical harm to others.A 9-year-old who has used a weapon toward his
mother and caused physical harm to others.
Which of the following patients should the nurse see FIRST? - correct answer
✔A patient who took 10 methylphenidate (Ritalin) and has a blood pressure of
160/100.CORRECT— most unstable patient; assess for restlessness, dilated
pupils, tremors, and seizures. Stimulant like amphetamines, improves
alertesness and concentration.
Which of the following patients should the nurse see FIRST? - correct answer
✔A 35-year-old who had a hysterosalpingogram is experiencing tachycardia,
and has a generalized rash.(2) CORRECT— x-ray of the cervix, uterus, and
fallopian tubes performed after the injection of a contrast medium; assess for
