a patient asks the nurse whether he is a good candidate to use a cpap machine the nurse reviews the clients history which condition would contraindica
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine?

Correct answer: A

Rationale: The correct answer is that the patient is in the late stage of dementia. In late-stage dementia, individuals may have an inability to follow commands and understand instructions independently, which are essential for proper installation and use of a CPAP machine. This makes using a CPAP machine challenging and potentially ineffective for patients in this condition. Choice B, having a history of bronchitis, does not contraindicate the use of a CPAP machine. In fact, CPAP therapy can be beneficial for patients with respiratory conditions like bronchitis. Choice C, a history of suicidal gestures/attempts, while concerning for the patient's mental health, does not directly contraindicate the use of a CPAP machine. Choice D, being on beta-blockers, is not a contraindication for CPAP machine use. Beta-blockers are commonly used medications for various conditions and do not interfere with the use of a CPAP machine.

2. The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?

Correct answer: D

Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.

3. You are caring for Thomas N., a 77-year-old man with edema in his legs and a fluid restriction. You have been assigned to weigh him daily. Based on these symptoms and the care he is receiving, what disorder is he most likely affected by?

Correct answer: C

Rationale: Thomas N.'s symptoms of edema in his legs and fluid restriction point towards congestive heart failure (CHF) rather than dementia or diabetes. In CHF, patients often present with dependent edema in their legs due to excessive blood volume, leading to fluid intake restrictions and a low-salt diet. Daily weight monitoring is crucial in CHF to assess fluid retention or loss. Diabetes primarily affects blood sugar levels, dementia is a cognitive disorder, and 'Contiguous heart disease' is not a recognized medical term, making choices A, B, and D incorrect in this scenario.

4. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

5. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Correct answer: B

Rationale: Encouraging range of motion and ambulation is an effective preventive measure for deep vein thrombosis in post-surgical clients. Mobility helps improve blood circulation, reducing the risk of clot formation. Elastic stockings help prevent blood pooling and clotting in the legs by providing external pressure to support venous return. Massaging the legs twice daily may help with circulation but is not as effective as promoting movement and ambulation. Placing pillows under the knees is a comfort measure and does not directly address the prevention of deep vein thrombosis.

Similar Questions

A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
A patient is deciding whether they should take the live influenza vaccine (nasal spray) or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?
A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?
A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the healthcare provider?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses