Wednesday, May 09, 2007

More NCLEX Practice

TRUE or FALSE. The best explanation a nurse can give for wrapping a client’s stump after leg amputation is to decrease the swelling.

TRUE. Wrapping a stump helps reduce edema and shapes the residual limb in a firm cone-shaped form for the prosthesis

TRUE OR FALSE. A client who is taking monoamine oxidase inhibitor (MAOI) should be eating prunes.

FALSE. Prunes should be avoided as they can result in a sudden and severe increase in blood pressure caused by high levels of tyramine. If this blood pressure is not controlled immediately, intracranial hemorrhage and death may result. This client should be eating fresh vegetables.


Appropriate placement of a nasogastric tube is associated with which of the following assessment techniques?

A. Listening for bowel sounds
B. Palpating over the epigastric region
C. Aspirating drainage through the nasogastric tube
D. Inserting the open end of the nasogastric tube into water

Answer: C. The nurse should instill air into the tube with a syringe and listen to a stethoscope for the air passing into the stomach or aspirate gastric contents. The other options are not identified as measures for verifying tube placement.


A nurse is asked to obtain the vital signs on a sleeping 4-month-old infant. Which of the following assessments would the nurse obtain first?

A. Apical pulse
B. Blood pressure
C. Axillary temperature
D. Respiratory rate

Answer: D. This is the least intrusive because the nurse does not need to touch the infant. The other assessments require touching and possibly disturbing the client. If an infant fusses or cries, the accuracy of the vital signs will decrease.

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