Question

The nurse is providing care for a client diagnosed with Graves' disease. Which of the following nursing interventions should be included in the client's care to provide maximum comfort?

Answer 1

Correct Answers:

Maintain the client's room at a cool temperature.

Rationale :

🧊Clients with Graves’ disease experience an increased basal metabolic rate, leading to heat intolerance and a preference for cool environments.

🔥The hypermetabolic state in hyperthyroidism causes excessive heat production, making warm conditions uncomfortable.

🏥Maintaining a cool room helps promote comfort and reduce restlessness associated with heat sensitivity.

🌡️Extra blankets or high room temperatures can exacerbate symptoms and increase patient distress.

📌Core Message

Clients with Graves’ disease are heat-intolerant due to their increased metabolic rate, so maintaining a cool environment enhances their comfort.

Answer 2

Correct Answers:

CPR is performed at a rate of 90-100 compressions per minute.

Rationale :

❤️The current CPR guidelines recommend a compression rate of 100–120 per minute to ensure adequate perfusion during cardiac arrest.

📉A rate of 90–100 is below the recommended threshold and may compromise cerebral and coronary perfusion.

💪Proper CPR technique includes full chest recoil, adequate depth, and appropriate rate, all of which are vital for success.

🚫This action must be corrected to ensure high-quality CPR is delivered and patient outcomes are optimized.

📌Core Message

Effective CPR requires a rate of 100–120 compressions per minute; anything lower, like 90–100, is inadequate and must be corrected.

Answer 3

Correct Answers:

Bedside commode
Incentive spirometer
Wound care supplies
Portable oxygen machine

Rationale :

🚽Clients with cellulitis and leg ulcers need wound care supplies for proper dressing changes and prevention of infection.

💨Those with emphysema benefit from portable oxygen and an incentive spirometer to improve lung expansion and reduce respiratory effort.

🚻A bedside commode is important for clients with decreased mobility due to leg ulceration and fatigue.

❌An epinephrine pen is unnecessary unless the client has a known allergy or risk of anaphylaxis.

📌Core Message

Clients discharged with emphysema and leg ulcerations need wound care supplies, oxygen support, and mobility aids to continue safe care at home.

Answer 4

Correct Answers:

Assess the child for additional symptoms of febrile illness.

Rationale :

👶The presence of fever, fussiness, and rhinorrhea suggests a potential underlying illness that must be evaluated before vaccination.

🩺Administering vaccines during acute illness can exacerbate symptoms or confound the diagnosis.

🌡️Assessment precedes intervention, including any antipyretics or postponing immunization.

⚠️Vaccines are typically deferred when a moderate or severe illness is suspected to prevent complications.

📌Core Message

When a child shows signs of illness before vaccination, the priority is assessment to determine if immunization is appropriate or should be postponed.

Answer 5

Correct Answers:

Gelatin
Ice cream
Pudding

Rationale :

🍮Gelatin is a commonly accepted item on a clear liquid diet, as it is fully liquid at body temperature and leaves no residue.

🍦However, ice cream and pudding are not permitted on a true clear liquid diet because they are opaque, contain dairy, and require digestion.

❌These items are part of a full liquid diet, not a clear one, which is usually ordered in preparation for diagnostic procedures or to rest the GI tract.

🔬The correct clear liquid choices should include transparent and non-residue fluids, and this answer contradicts the standard dietary guidelines for clear liquid diets.

📌Core Message

Only transparent fluids and non-residue items like gelatin are included in a clear liquid diet; ice cream and pudding are not appropriate.

Answer 6

Correct Answers:

4 to 12 hours after the administration of the insulin

Rationale :

🕓NPH insulin is an intermediate-acting insulin that peaks between 4 to 12 hours after injection.

💉During this peak time, the blood glucose level is at the highest risk of dropping, requiring patient education.

🩺Understanding insulin peaks helps prevent hypoglycemia through timely meals or snacks.

📚The nurse’s role is to educate the client on recognizing symptoms and managing potential blood sugar drops.

📌Core Message

NPH insulin peaks 4–12 hours after administration, making that the highest risk period for hypoglycemia.

Answer 7

Correct Answers:

Provide the client with a touch-sensor call-button that requires a light tap to activate.

Rationale :

🖐️The client has gross motor function of the right hand but cannot perform full upper arm movements, limiting traditional call bell use.

🔔A touch-sensitive call system ensures the client can safely and independently communicate needs.

🛏️Frequent rounding is helpful but does not replace the need for client-initiated communication.

📱Providing phone numbers or communication boards is ineffective if motor ability or literacy is impaired.

📌Core Message

Clients with limited mobility but preserved hand function need adaptive devices like touch-sensitive call buttons to communicate effectively.

Answer 8

Correct Answers:

Increasing the administration of anti-anxiety medications

Rationale :

🌿Palliative care focuses on comfort and symptom relief, including addressing emotional distress such as anxiety.

😰Clients with end-stage renal failure may experience anxiety and restlessness, especially when curative treatment is withdrawn.

💊Use of anti-anxiety medications enhances the quality of life and aligns with palliative goals.

🚫Reducing oxygen or pain meds contradicts the comfort-focused nature of palliative care.

📌Core Message

Palliative care prioritizes relief of anxiety and discomfort, often involving increased use of anti-anxiety medications for client well-being.

Answer 9

Correct Answers

respiratory rate [ Immediate Concern ]
urine output [ Immediate Concern ]
heart sounds [ Immediate Concern ]
blood pressure [ Immediate Concern ]
temperature [ Secondary Concern ]
heart rate [ Immediate Concern ]

Rationale :

💨A respiratory rate of 30 indicates tachypnea, a possible sign of respiratory compromise or cardiac stress.

🧪Decreased urine output with dark, odorous urine suggests dehydration or renal dysfunction.

❤️Muffled heart sounds may signal pericardial effusion, which could lead to cardiac tamponade.

📉A low BP and elevated HR are indicative of hemodynamic instability and need immediate attention.

🌡️While a slightly elevated temperature may suggest inflammation or infection, it is not as critical as the other findings.

📌Core Message

The client's vital signs and findings show respiratory distress, low perfusion, and possible cardiac complications, requiring urgent intervention.

Answer 10

Correct Answers

Elevated creatinine [ Urinary Tract Infection ]
History of cardiac surgery [ Post-Pericardiotomy Syndrome ]
Tachycardia [ Pulmonary Embolism ; Post-Pericardiotomy Syndrome ]
Distant heart sounds [ Post-Pericardiotomy Syndrome ]
Absence of dyspnea [ Pulmonary Embolism ]

Rationale :

🧪An elevated creatinine is a hallmark of renal impairment, often associated with a UTI or dehydration.

💓Tachycardia is a nonspecific but common finding in both PE and post-pericardiotomy syndrome due to stress and hypoxia.

💔Distant heart sounds and a history of cardiac surgery are typical signs of post-pericardiotomy syndrome.

❌The stated “absence of dyspnea” is likely a misleading option, as dyspnea is present in PE—but chosen per given instructions.

📌Core Message

Client’s findings suggest renal involvement, possible PE, and post-pericardiotomy syndrome, each requiring specific evaluation based on clinical history and presentation.

BP	92/76 mHg
HR	126 bpm
RR	30/min
Temperature	99.8°F
SpO2	95% room air

Parameter	Immediate Concern	Secondary Concern	No Treatment Required
respiratory rate
urine output
heart sounds
blood pressure
temperature
heart rate

BP	92/76 mHg
HR	126 bpm
RR	30/min
Temperature	99.8°F
SpO2	95% room air

BP	88/70 mmHg
HR	128 bpm
RR	32/min
Temperature	100°F
SpO2	98% nasal cannula 2 lpm

Test	Client Result	Normal Range
HBG	11.0 g/mL	12–18 g/mL
HCT	34%	38%–48%
WBC	11,000 µL	4500–11,000 µL
BUN	28 mg/dL	7–20 mg/dL
Cr	1.9 mg/dL	0.7–1.3 mg/dL
NA	144 mEq/L	135–145 mEq/L
K	3.6 mEq/L	3.5–5.0 mEq/L
CI	96 mEq/L	97–103 mEq/L
CO2	22 mEq/L	22–26 mEq/L
Sed Rate	62 mm/hr	0–22 mm/hr
CRP	0.56 mg/dL	<0.3 mg/dL
BG	90	<99 mg/dL
Urine SG	1.025	1.010–1.1025

NCLEX PN-Practice Exam-3

No.

1 :
The nurse is providing care for a client diagnosed with Graves' disease. Which of the following nursing interventions should be included in the client's care to provide maximum comfort?

2 :
A 52-year-old hospitalized client who was sitting in a chair has suddenly slumped over. The client is not breathing and is pulseless, and cardiopulmonary resuscitation (CPR) is in progress by another nurse. Which action would prompt the nurse to intervene?

3 :
A client who was treated for emphysema and cellulitis with leg ulcerations is being discharged home with home health care services. The nurse knows that discharge planning for this client should involve which materials and equipment? Select all that apply.

4 :
A parent brings a 12-month-old child to the pediatrician's office for an influenza vaccination. Before administering the immunization, the nurse notes the child is acting fussy, is warm and flushed, and has rhinorrhea. Which of the following is the nurse's priority action?

5 :
The nurse is caring for a client who is ordered a clear liquid diet. Which of the following items are permitted on this type of diet? Select all that apply.

6 :
The nurse has just completed administering a client's morning dosage of NPH insulin. The client asks the nurse, "If my blood sugar is going to drop, when will it occur?" Which of the following is the nurse's best response?

8 :
The nurse is participating in the care of a client with end-stage renal failure. The physician orders a palliative care consult because the client wishes no further medical interventions. Which of the following should the nurse anticipate based on her knowledge of palliative care?

9 :
The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.

Correct Answers

10 :
The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.

Correct Answers

Item	Urinary Tract Infection	Pulmonary Embolism	Post-Pericardiotomy Syndrome
Elevated creatinine
History of cardiac surgery
Tachycardia
Distant heart sounds
Absence of dyspnea

NCLEX PN-Practice Exam-3

No.

1 : The nurse is providing care for a client diagnosed with Graves' disease. Which of the following nursing interventions should be included in the client's care to provide maximum comfort?

2 : A 52-year-old hospitalized client who was sitting in a chair has suddenly slumped over. The client is not breathing and is pulseless, and cardiopulmonary resuscitation (CPR) is in progress by another nurse. Which action would prompt the nurse to intervene?

3 : A client who was treated for emphysema and cellulitis with leg ulcerations is being discharged home with home health care services. The nurse knows that discharge planning for this client should involve which materials and equipment? Select all that apply.

4 : A parent brings a 12-month-old child to the pediatrician's office for an influenza vaccination. Before administering the immunization, the nurse notes the child is acting fussy, is warm and flushed, and has rhinorrhea. Which of the following is the nurse's priority action?

5 : The nurse is caring for a client who is ordered a clear liquid diet. Which of the following items are permitted on this type of diet? Select all that apply.

6 : The nurse has just completed administering a client's morning dosage of NPH insulin. The client asks the nurse, "If my blood sugar is going to drop, when will it occur?" Which of the following is the nurse's best response?

8 : The nurse is participating in the care of a client with end-stage renal failure. The physician orders a palliative care consult because the client wishes no further medical interventions. Which of the following should the nurse anticipate based on her knowledge of palliative care?

9 : The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.

Correct Answers

10 : The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.

Correct Answers

1 :
The nurse is providing care for a client diagnosed with Graves' disease. Which of the following nursing interventions should be included in the client's care to provide maximum comfort?

2 :
A 52-year-old hospitalized client who was sitting in a chair has suddenly slumped over. The client is not breathing and is pulseless, and cardiopulmonary resuscitation (CPR) is in progress by another nurse. Which action would prompt the nurse to intervene?

3 :
A client who was treated for emphysema and cellulitis with leg ulcerations is being discharged home with home health care services. The nurse knows that discharge planning for this client should involve which materials and equipment? Select all that apply.

4 :
A parent brings a 12-month-old child to the pediatrician's office for an influenza vaccination. Before administering the immunization, the nurse notes the child is acting fussy, is warm and flushed, and has rhinorrhea. Which of the following is the nurse's priority action?

5 :
The nurse is caring for a client who is ordered a clear liquid diet. Which of the following items are permitted on this type of diet? Select all that apply.

6 :
The nurse has just completed administering a client's morning dosage of NPH insulin. The client asks the nurse, "If my blood sugar is going to drop, when will it occur?" Which of the following is the nurse's best response?

8 :
The nurse is participating in the care of a client with end-stage renal failure. The physician orders a palliative care consult because the client wishes no further medical interventions. Which of the following should the nurse anticipate based on her knowledge of palliative care?

9 :
The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.

10 :
The nurse is caring for a 60-year-old man who underwent cardiac surgery 3 weeks ago.