NCLEX
Practice Test 14
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A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

  • Solution

    Option A: Lovenox injections should be given in the abdomen, not in the deltoid muscle.

    Options C and D: The client should not aspirate after the injection or clear the air from the syringe before injection.

The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

  • Solution

    The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip.

The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

  • Solution

    The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect.

The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

  • Solution

    A nonstress test determines periodic movement of the fetus.

    Options A, C, and D: Non-stress test does not determine lung maturity, show contractions, or measure neurological well-being.

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

  • Solution

    The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children.

The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below, select where the Tail of Spence is.

  • Solution

    Answer: A.

    The Tail of Spence is located in the upper outer quadrant of the breast.

The infant is admitted to the unit with tetralogy of falot. The nurse would anticipate an order for which medication?

  • Solution

    The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect (VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An overriding aorta. He will be treated with digoxin to slow and strengthen the heart.

    Options B, C, and D: Epinephrine, aminophylline, and atropine will speed the heart rate and are not used in this client.

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

  • Solution

    The output of 300 mL is indicative of hemorrhage and should be reported immediately.

    Option A: Turning the client to the left side does nothing to help the client.
    Options B and C: Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not an appropriate action.

The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

  • Solution

    The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones.

    Option B: Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy.
    Option C: Hold the tracheotomy with the nondominant hand while removing the old tie is not the best way to prevent the client from coughing out the tracheotomy.
    Option D: Asking the doctor to suture the tracheotomy in place is not appropriate.

The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

  • Solution

    The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps

    Options A, C, and D: Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor.

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