Study NCLEX Practical Nursing with Answers 100th Edition

Study NCLEX Practical Nursing with Answers 100th Edition

1. A nurse is caring for an African-American client. The nurse enters the room, and following a greeting and introduction to the client, the nurse begins to describe the procedure for a prescribed soapsuds enema. The client turns away from the nurse. Which nursing action is appropriate?

A. Continue with the explanation
B. Tell the client that the enemas are necessary
C. Walk around to the client and ask the client what the problem might be
D. Leave the room and return later to continue with the explanation

Answer: A. Continue with the explanation

Rationale: In the African-American culture, direct eye contact may be viewed as being rude. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. Leaving the room and returning later to continue with the explanation may be viewed as a rude gesture by the client. Option 2 is nontherapeutic.

Test-Taking Strategy: Understanding the characteristics of this cultural group will assist in answering the question. Also, use of therapeutic communication techniques will direct you to option A. Review the characteristics of this cultural group if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Fundamental Skills
References: Jarvis, C. (2004). Physical examination and health assessment (4th ed.). Philadelphia: W.B. Saunders, p. 59.
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 133.

2. A nurse is assigned to care for a client who has just returned to the nursing unit following renal biopsy. The nurse plans to do which of the following to properly care for this client for the remainder of the shift?

A. Limit intake of oral fluids
B. Withhold all pain medication
C. Test the urine for occult blood
D. Ambulate the client twice in the hallway

Answer: C. Test the urine for occult blood

Rationale: Following renal biopsy, serial urine samples are tested for occult blood. The nurse encourages fluid intake to reduce possible clot formation at the biopsy site. Narcotic analgesics are often used to manage the renal colic pain that some clients feel after this procedure. The nurse ensures that the client remains in bed for at least 24 hours. The nurse checks the client’s vital signs and puncture site frequently.

Test-Taking Strategy: Use the process of elimination. Begin to answer this question by recalling that encouraging fluid intake will reduce clotting at the site, whereas ambulation could initiate or enhance bleeding at the biopsy site. Thus, options 1 and 4 are eliminated first. Knowing that pain and bleeding are potential concerns after this procedure guides you to select option 3 over option B. Review postprocedure care following renal biopsy if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Renal
Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 756-757.

3. A nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which of the following foods?

A. Ice cream
B. Cheese
C. Garden peas
D. Strawberries

Answer: B. Cheese

Rationale: Foods that are allowed on an acid-ash diet include meat, fish, shellfish, cheese, eggs, poultry, grains, cranberries, prunes, plums, corn, lentils, and foods with high amounts of chlorine, phosphorus, and sulfur. Foods that are not included are milk and milk products such as ice cream, all vegetables except corn and lentils, all fruits except cranberries, plums, and prunes, and foods containing high amounts of sodium, potassium, calcium, and magnesium.

Test-Taking Strategy: Focus on the issue—an acid-ash diet. Recalling the foods allowed in this diet will direct you to option B. Review this diet if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Renal
References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 536.
Nix, S. (2005). Williams’ basic nutrition & diet therapy (11th ed.). St. Louis: Mosby, pp. 406-407.

4. A nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. The nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome?

A. Vomiting and headaches
B. Abdominal pain and hypotension
C. Lethargy and hypertension
D. Hypertension and sleepiness

Answer: A. Vomiting and headaches

Rationale: A complication that can occur during early dialysis is disequilibrium syndrome. This syndrome results from a high osmotic gradient in the brain following the rapid fluid removal that can occur during hemodialysis. Because solutes are not removed as quickly from the cerebrospinal fluid (CSF) and brain, fluid from the circulation shifts into the brain, causing cerebral edema. The client may exhibit nausea and vomiting, confusion, headaches, restlessness, twitching, muscle cramps, and seizures. Options 2, 3, and 4 do not identify signs of disequilibrium syndrome.

Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar. From the remaining options, focusing on the name of the syndrome will direct you to option A. Review the signs and symptoms of disequilibrium syndrome if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Renal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 784.

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