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NUR 101 (NUR101)
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NCLEX RATIONALES
1. Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic
medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes,
including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to
torsades de pointes.
2. Body weight is the most reliable indicator of fluid loss for infants and young children.
3. Measles, mumps rubella (MMR) is correct. A 1-year-old child should receive the first of two doses of
the MMR vaccine.
Diphtheria, tetanus and acellular pertussis (DTaP) is incorrect. By 1 year of age, the child should
have already received three doses of DTaP: at 2 months, 4 months, and 6 months. The child should
receive a fourth dose at 15 months of age.
Varicella (VAR) is correct. A 1-year-old child should receive the first of two doses of the VAR
vaccine.
Rotavirus (RV) is incorrect. A 1-year-old child should have received the RV vaccine in a two or three
dose series starting at 2 months of age.
Human papillomavirus (HPV4) is incorrect. A child should receive a three dose series of the HPV4
vaccine at 11 or 12 years of age.
4. The client has paralysis from the level of the defect down. In the majority of cases, this condition
affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent
emptying of the bladder can result in stasis and urinary tract infections.
5. Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a
second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an
artery, a vein, or the heart.
6. Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic
(haloperidol) medications that requires emergency medical intervention. Manifestations of NMS are
sudden and include changes in level of consciousness, seizures, and stupor.
7. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination
following delivery. Immunization during pregnancy is contraindicated because of possible injury to the
developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1
month.
8. Any adult who has a respiratory rate of over 30/min requires immediate attention. Additionally, this
patient is unconscious, which constitutes altered mental status. This client is the client he nurse should
care for first.
9. Plan the client's schedule to allow time for rituals.
10. OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels driven to
MY
perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or
distress. In the initial phase of treatment, the nurse should allow adequate time for the client to perform
rituals to help the client handle anxiety.
,11. Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause
bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle
relaxation.
12. Noxious gas: Following the principle of mitigation, the nurse should facilitate evacuation out of the
building to prevent exposure to the harmful gas and set up the triage site at a nearby location.
13. Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the
end of the pregnancy as the enlarging uterus places pressure on the bladder.
14. Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate
indication of true labor.
15. Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care
workers refrain from intentionally inflicting harm to clients.
16. Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium
toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous
exercise during hot weather, she should take care to replace any water and sodium that have been
lost through profuse sweating. This also applies to other factors that can cause the client to become
dehydrated, such as having diarrhea or taking diuretics.
17. Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they
become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to
increase the amount of oxygen available to the tissues.
Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes
permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the
ribs flare outward. This produces the barrel chest typical of emphysema clients.
Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips
of the fingers enlarge, and the nails become extremely curved from front to back.
18. Rice, potatoes, and oranges
19. This group of foods contains the highest level of carbohydrates.
MY ANS
20. What part of the exam makes you most nervous?"
21. This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of
MY ANSWER
clarification to encourage the client to tell the nurse more about her concerns.
22. Red meat and organ meat
23. This client has a deficiency in iron and needs instruction about foods that are rich
MY ANSWER
sources of iron. A diet rich in red and organ meat provides iron, which is what the client
24.
25.
needs to improve anemia.
26.
23. a nurse is planning to teach a client about a low-potassium diet. Which of the following
foods should the nurse instruct the client to avoid? Yogurt, Orange Juice
24. Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The
nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord.
Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate
due to ineffective function of the bladder muscles.
, Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could
cause the client to develop a paralytic ileus.
Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or
coughing and drooling noted with oral intake.
25. A nurse is caring for a client who is admitted with acute psychosis and is being treated
with haloperidol (Haldol). The nurse should suspect that the client may be experiencing
tardive dyskinesia as an adverse reaction when the client exhibits which of the following?
(Select all that apply.)
a) Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as tongue thrusting and lip smacking.
.
Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make
repetitive and uncontrollable movements such as facial grimacing and eye blinking.
Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and
involuntary movements of the head, neck, trunk, and extremities can occur in tardive dyskinesia.
26. nurse is providing education about introducing new foods to the parents of a 4-month-old
infant. The nurse should recommend that the parents introduce which of the following
foods first?
Iron-fortified cereal should be the first solid food introduced to the
infant.
29. Pull the curtains around the client's bed: Pulling the curtains around the client's bed assures
privacy for the client should someone open the door or enter the room.
30. Ask the client to describe the situation. WER
a. During the acute phase following assault, the nurse should encourage the client to provide
information which may be helpful with treatment and to reduce the client’s anxiety.
31.
32. A nurse accidentally administers the wrong medication to a client, which results
in a severe allergic reaction and prolongs the client’s hospitalization. The client
could rightfully sue the nurse for which of the following? Malpractice
The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct
another professional would exercise in similar circumstances and that failure causes harm. This nurse
has made an error that harmed the client.
33. A client on a mental health unit refuses treatment and asks to be discharged from
the hospital against medical advice. The nurse notifies the client's provider, who
tells the nurse to restrain the client, if necessary, to prevent him from leaving the
hospital. Restraining this client would be considered which type of civil action by
the nurse? False imprisonment
, 34. A nurse is admitting a child who has leukemia. Which of the following clients should the
nurse place in the same room with this child? A child who has nephrotic syndrome.
35. A nurse is assessing a client who is 48 hr postoperative following abdominal
surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision (yellow-green drainage is
indicative of an infection).
36. a nurse is providing dietary teaching to the parents of a newborn who is being breastfed.
The nurse should instruct that the transition to whole mill can occur which of the
following ages? At the age of 12 moths.
37. A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension
form. Which of the following actions should the nurse take before administering each dose?
Shake the container vigorously. This ensures the particles of the medication are evenly
distributed.
38. A nurse is caring for a child who is admitted with suspected acute appendicitis.
Which of the following manifestations should indicate to the nurse that the child's
appendix is perforated? Sudden decrease in abdominal pain
39. an older adult client who lives alone tells a clinic nurse that he is unable to drive
himself to the store and is afraid to cook on the stove. which of the following
community resources should the nurse recommend for this client? Meals on
wheel
40. A nurse is instructing a group of adult clients about nutrition. The nurse
should include which of the following as the recommended amount of
vegetables servings per day?
2 1/2 cups per day
41. A nurse is caring for a client who has Cushing's syndrome. The nurse should
recognize that which of the following are manifestations of Cushing's
syndrome? (Select all that apply.)
Moon face
alopecia
Purple striations
Buffalo hump
42. a nurse is providing dietary teaching for a client who has just learned that she has types 2
diabetes mellitus. the nurse should explain that which of the following sweetness will add
calories to the client’s carbohydrate count? Sorbitol
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