NCLEX® Question Traps

A 29-year-old client suffered a subarachnoid hemorrhage 4 months ago and has now been diagnosed with post-traumatic stress disorder (PTSD). Based on this diagnosis, the nurse knows that the client would most likely demonstrate which of the following symptoms?

A client is brought into the ED. The client is highly anxious and upset and her hands are shaking. She tells the nurse that she can’t breathe. Which action should the nurse perform first?

A client in DKA has an order for an insulin infusion at 5 units per hour. The nurse is setting up IV insulin, 100 units/100 mL as a secondary line, with D10W as the primary infusion. The nurse follows the 6 rights of medication administration, clamps the secondary tubing, spikes the insulin bag, squeezes the chamber until it is ⅔ full, and slowly opens the roller clamp to prime the tubing. The nurse then cleanses the Y-port closest to the client and connects the secondary tubing, ensuring the bag is hanging above the primary infusion. The pump is programmed to run the secondary infusion at 5 mL per hour, so the nurse starts the pump. Which statement correctly describes what is wrong with this situation?

A community nurse goes to visit an elderly client living alone. The client’s spouse passed away 6 months ago and since then the client has had a 20 lb weight gain and reports the inability to cook and eats out a lot. Further assessment reveals the client has not seen a provider in 2 years, is on a limited income, and does not participate in any social activities. The nurse understands that Mr. Thomas would benefit most from which of the following?

A 19-year-old college student is seen in the university health clinic for symptoms of dehydration and weight loss. The client is a member of the school’s track team and spends several hours a day training. Which information should the nurse give to this client to prevent dehydration associated with excessive exercise?

A community health nurse is teaching a new mother about caring for her baby. The mother is worried about her child developing food allergies and asks the nurse what she can do to prevent it. Which information is most appropriate in this situation?

A nurse is caring for a client who is Catholic and is NPO after abdominal surgery. The client’s priest visits to offer communion. Which action of the nurse is most appropriate?

A 6-year-old child has been brought in for care and treatment after suffering from physical abuse by her father. The child is experiencing a post-traumatic fight-or-flight response. Which signs or symptoms would the nurse most likely expect to initially see in this client?

A 15-year-old female client was diagnosed with type 1 diabetes a year ago. The client is now being seen in the healthcare clinic because her mother is concerned that she is losing too much weight. The client admits that she sometimes goes without eating for long periods and uses very little insulin. Which of the following interventions would be most appropriate for the nurse to help this client?

A client has been brought into the emergency department after overdosing at home on acetaminophen tablets. The nurse sets up a gastric lavage kit according to provider orders. The nurse prepares to insert the tube into the client’s nose. Which action should the nurse perform first?