NCLEX Preparation Course - Critical Thinking Exercises III (Questions 21-30)

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21. Which of the following would the nurse include in the discharge teaching of a client diagnosed to have shigellosis?

a) instruct client on the oro-fecal route transmission of disease
b) instruct the client on proper disposal of tissue wipes
c) instruct client on covering the nose and mouth when coughing and sneezing
d) instruct client on importance of daily bath

22. What is a characteristic of Marfan Syndrome?

a) hypertension
b) tall, thin skeleton
c) obesity
d) hypertrophy of muscles in the thighs and legs

23. A client with pheochromocytoma is scheduled for adrenalectomy. Which of the following should be given highest priority after the surgery?

a) fluid and electrolyte replacement
b) monitoring of blood pressure
c) measurement of hourly urine output
d) assessment of blood gases

24. Which of the following clients should be assessed first by the nurse?

a) the client with ileostomy which has no drainage for the past 6 hours
b) the client who had undergone appendectomy 24 hours ago with temperature of 37.7 C
c) the client who had vaginal delivery 3 hours ago, with reddish vaginal discharge
d) the client who had colostomy 3 days ago, passing malodorous flatus from the stoma

25. A 60-year old client is for prostatectomy. He asks the nurse on the safe time when he can resume his sexual activity. What is the appropriate response by the nurse?

a) after 6 months, it is safe for you to resume sexual activity
b) after 1 month, you are allowed to resume sexual activity
c) it is necessary that you abstain from sexual activity for 1 year
d) most probably, your physician will allow you to resume sexual activity within two weeks after discharge

26. Four clients made a call to the unit. Which among these clients should you make a return call first?

a) a client who had been crying all day because her boyfriend died
b) a client with bipolar disorder because he is unable to go to the restaurant
c) an alcoholic who says, "My family doesn't care about me. They will be sorry later."
d) a client who feels anxious because she had just been told by his physician that she has breast tumor

27. Which of the following is most effective nursing action to prevent thrombophlebitis in a bedridden client?

a) avoid raising knee-gatch
b) massage the legs
c) apply moist heat in the legs
d) limit fluid intake

28. What is the appropriate action by the charge nurse when an RN's breath smells alcohol after her break?

a) assign her patients to the other nurses and send her home
b) take the nurse to the conference room and interview her
c) allow her to continue caring for her parents
d) call the security

29. The client had been diagnosed to have Bell's palsy. Which of the following is not appropriate nursing intervention?

a) encourage active facial muscle exercises
b) protect involved eye
c) apply ice pack on the involved area
d) administer steroids as ordered

30. The client has the following laboratory results: serum potassium is 5.9 mEq/L, serum sodium is 142 mEq/L. Which action is most essential for the nurse to do?

a) administer normal saline/IV as ordered
b) do cardiac monitoring
c) administer oxygen per nasal cannula
d) administer potassium chloride per slow IV drip as ordered

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