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40. For a client who has ataxia, which of the following tests would

be performed to assess the ability to ambulate?

a. Kernig's

b. Romberg's

c. Riley-Day's

d. Hoffmann's

Answer: b

Rationale: Romberg's test is the ability to maintain an upright position without swaying

when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction,

is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.

41. A client admitted to a surgical unit for possible bleeding in the cerebrum

has vital signs taken every hour to monitor to neurological status. Which

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a. Pupillary checks

b. Spinal tap

c. Deep tendon reflexes

d. Evaluation of extrapyramidal motor system

Answer: a

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as it becomes displaced by blood, tumor, etc.


42. Assessing for immediate postoperative complications, the nurse knows that

a complication likely to occur following unresolved atelectasis is

a. Hemorrhage

b. Infection

c. Pneumonia

d. Pulmonary embolism

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Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated

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43. A young client is in the hospital with his left leg in Buck's traction. The

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b. Prevent footdrop

c. Keep the client from sliding down in bed

d. Prevent pressure areas on the foot

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Respiratory Disorders NCLEX Review

1.    A Mantoux test signifies exposure to Mycobacterium Tubercle Bacilli. The test is read for how many hours after injection?
a.    1 hour
b.    12-24 hours
c.    48-72 hours
d.    2 hours

2.    A nurse is about to perform a Mantoux test. The test is done by using which route?
a.    Intradermal
b.    Intramuscular
c.    Subcutaneous
d.    IM with the use of Z-track method

3.    A client is suspected to have an HIV. The nurse knows that in the Mantoux test result, a client is considered positive with HV if he has an induration of:
a.    More than 10 mm
b.    3mm
c.    4 mm
d.    5 mm

 

Answers: 1.    Answer: C. Mantoux test is read 48-72 hours after injection.
2.    Answer: A. Mantoux tests are done intradermally.
3.    Answer: D. Mantoux test is considered positive for Mycobacterium Tubercle Bacilli if the induration is 10 mm or more. For HIV positive clients, induration of 5mm is considered positive. 

This is updated once a week.
 

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01/23/2011 14:56
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01/17/2011 08:59
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01/17/2011 08:58
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