Wednesday, December 5, 2007

Sample NCLEX Questions with Rationale iv

Topic: Physiological Integrity

A 30-year-old client has just been admitted to the psychiatric unit with the diagnosis of manic episode. The client manifests an excess of energy, and it is difficult for her to sit still. The most useful activity for this client that the nurse might suggest would be to

A) Empty wastebaskets on the unit.

B) Engage in occupational therapy and group exercises.

C) Play volleyball outside.

D) Deliver linen to the rooms.

Answer: D

D) This activity would channel her energy, but not increase the external stimuli as the group activities would do. Competitive activities are nontherapeutic because they are so stimulating.

NP:P; CN:PS; CA:PS

Topic: Psychosocial Integrity

The best rationale for the nurse introducing her- or himself to a blind client and telling him exactly what will be administered is to

A) Illustrate the principle of open communication.

B) Encourage and utilize clear communication.

C) Follow steps for beginning a nurse-client relationship.

D) Decrease the client's anxiety and fear of the unknown.

Answer: D

D) Blind clients become anxious when they hear someone enter the room without talking.

NP:E; CN:PS; CA:PS

Topic: Psychosocial Integrity

The priority rationale for checking a client's platelet count following heparin therapy is to

A) Check the client's level of anticoagulation.

B) Detect heparin-induced thrombocytopenia

C) Determine if the client requires an anticoagulant alternative.

D) Monitor the client's heparin absorption.

Answer: B

B) Up to 10 percent of clients receiving heparin therapy develop heparin-induced thrombocytopenia. If the platelet count drops below 10,000/cu mm or 40 percent below the pretreatment level, the client has this condition and it contraindicates the continued use of heparin. He may then require an alternate medication.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

A young client is in spinal shock and will be for a few weeks after being struck by a car. The nurse will be able to recognize that this state is resolving when

A) His legs move.

B) Hyperreflexia occurs.

C) His vital signs stabilize.

D) He regains sensations but not motion in his upper extremities.

Answer: B

B) Reflex activity begins to return below the level of injury because of automatic activity inherent in nervous tissue.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

Immediately following a thoracentesis, which clinical manifestations could indicate that a complication has occurred and the physician should be notified?

A) Increased pulse and pallor.

B) Increased temperature and blood pressure.

C) Hypotension and hypothermia.

D) Serosanguineous drainage from the puncture site.

Answer: A

A) Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than one liter of fluid is removed at one time to prevent this from occurring. NP:E; CN:PH; CA:M

Topic: Physiological Integrity

The nurse has orders to suction a 50-year-old client. One nursing action necessary to prevent hypoxia during the procedure is to

A) Ensure that the catheter is no more than three-quarters the diameter of the nares.

B) Limit suction time to 30 seconds, at intervals of three minutes.

C) Hyperinflate the lungs with 100 percent oxygen prior to and following suctioning.

D) Suction no more than three consecutive times before administering oxygen.

Answer: D

D) Preoxygenation of the lungs prevents hypoxia during the suctioning procedure in a client requiring frequent treatments. (A) The catheter should be one-half the diameter of the nares, (B) suctioning should be limited to 5-10 seconds at one time, and (D) should be to allow the client to breathe normally or administer oxygen between periods of suctioning.

NP:I; CN:PH:CA:M

Topic: Physiological Integrity

A client, age 60, is admitted to the hospital for a possible low intestinal obstruction. His preoperative work-up indicates vital signs of BP 100/70, P 88, R 18, and temperature of 96.4 degrees F. Listening to bowel sounds, the nurse would expect to find

A) Gurgling bowel sounds.

B) Hyperactive, high-pitched sounds.

C) Absence of bowel sounds.

D) Tympanic, percussion sounds.

Answer: B

B) The nurse will note high-pitched sounds with an obstruction. Paralytic ileus has no bowel sounds or gurgling. Gastric distention will have tympanic sounds.

NP:AN; CN:PH; CA:M

Topic: Physiological Integrity

The first nursing action immediately after a precipitous birth in the emergency room is to

A) Remove any mucous from the baby's mouth to clear the airway.

B) Wrap the baby tightly to keep it warm.

C) Place the baby on the mother's abdomen to maintain warmth.

D) Prepare for delivery of the placenta.

Answer: A

A) The first priority is to determine that the infant's airway is clear. Keeping the baby warm is also a very important nursing intervention, but not the first action to be done. After delivery and clearing the infant's airway, place the infant head-down on his mother's abdomen. This action facilitates contraction of the uterus and provides warmth for the baby.

NP:I; CN:H; CA:MA

Topic: Health Promotion and Maintenance

An RN's friend, who is also a nurse, is in her first trimester of pregnancy. While working in the hospital, the nurse knows that her friend should avoid

A) A client who has just been diagnosed with lupus erythematosus.

B) A 3-month-old infant with a generalized rash.

C) Any client with an infection.

D) A child with a fever and upper respiratory disorder.

Answer: B

B) German measles or rubella, if contracted in the first trimester of pregnancy, may result in a child with congenital malformations of the heart, eye and ear, as well as mental retardation.

NP:P; CN:H; CA:MA

Topic: Health Promotion and Maintenance

A common test used to determine fetal status in the presence of pre-eclampsia is the Nonstress Test (NST). If this test is "reactive," the nurse knows that it means

A) The test was abnormal, indicating a need for an immediate Oxytocin Challenge Test (OCT).

B) The test was normal, showing no change in FHR with fetal movement.

C) The test was normal, showing an increased fetal heart rate (FHR) with fetal movement.

D) Ultrasound is indicated to determine fetal habitat and placental placement.

Answer: C

C) Reactive = good outcome. Increased FHR with movement indicates normal reaction and adequate CNS integration.

NP:AN; CN:H; CA:MA

Topic: Health Promotion and Maintenance

The nurse is assigned a client who has just had a nasogastric tube inserted postoperatively. During the evaluation of his status, the nurse will check for

A) Infection.

B) Ulcerative colitis.

C) Electrolyte imbalance.

D) Gastric distention.

Answer: C

C) Nasogastric intubation can lead to the complication of electrolyte imbalance because of removing the gastric contents by suctioning. Large amounts of sodium and potassium are lost through the suctioning and, if not replaced via IV fluids, can lead to serious electrolyte imbalance.

NP:E; CN:PH; CA:S

Topic: Physiological Integrity

A client who has been near a family member with suspected tuberculosis has the Mantoux test. The results are 6 mm induration. The nurse will recommend to the client that

A) He begin on a drug protocol.

B) The Mantoux test be repeated.

C) He take the Tine test.

D) He do nothing because it is not 10 mm induration.

Answer: B

B) If the reaction (area of induration) is between 5 and 9 mm, a repeat test should be done. If the induration is 10 mm or more, it indicates that the client has had contact with the tubercle bacillus. The Tine test is not recommended for diagnosis and, if positive, the Mantoux will be done. When a definitive diagnosis of TB is made, a drug protocol will be administered.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

The most important measure to include in the nursing management for a child with cystic fibrosis would be to

A) Promote optimal nutrition with a high-protein, low-fat diet.

B) Administer only water-soluble vitamins.

C) Administer pancreatic enzymes before each meal.

D) Encourage lots of fluids, especially fruit juices.

Answer: C

C) Pancreatic enzymes should be administered before each meal in order to facilitate digestive processes in the child with cystic fibrosis. The diet is important, but without the pancreatic enzymes the nutrients will not be assimilated.

NP:I; CN:PH; CA:P

Topic: Physiological Integrity

A male client is being discharged from the hospital following a short hospitalization for angina. He will be sent home on the drug propranolol hydrochloride (Inderal). Which of the following statements would indicate to the nurse that he understands the actions of the drug?

A) "I will not discontinue the drug suddenly."

B) "I will monitor my blood pressure before each dose of the drug."

C) "I will need to take additional potassium supplements."

D) "I will need to have laboratory tests done every month."

Answer: A

A) Discontinuing the drug suddenly may result in an exacerbation of the angina and myocardial infarction. Laboratory tests are not drawn routinely and potassium supplements are not necessary with this drug.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

A client has the diagnosis of acute renal failure. The nurse assesses him for hyperkalemia. Monitoring his EKG, the nurse will observe for

A) Complete heart block.

B) Peaked T waves.

C) Ventricular arrhythmias.

D) Flattened T waves.

Answer: B

B) When the serum potassium exceeds 5.5 mEq/l, T waves become tall, narrow and pointed. Enhanced automaticity does not occur, nor does heart block as a result of hyperkalemia.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

If it is suspected that a child is abused, the legal responsibility of the staff who evaluated the case is that

A) The nurse is legally responsible for reporting a suspected child abuse.

B) Both the doctor and the nurse are legally responsible for reporting child abuse.

C) The doctor, not the nurse, is legally responsible for reporting child abuse.

D) Neither the doctor nor the nurse is legally responsible for reporting child abuse.

Answer: B

B) Both the nurse and doctor, independently, are legally responsible to report a suspected battered child to the proper authorities.

NP:AN; CN:H; CA:P

Topic: Health Promotion and Maintenance

A 42-year-old client is admitted with suspected cholelithiasis. Making an assessment of the client, the nurse should be alert to her complaints of

A) Fatty food intolerance several hours after eating.

B) Chronic pain in her lower right abdomen.

C) Chronic pain in her lower left abdomen.

D) Fatty food intolerance while eating.

Answer: A

A) Pain is probably due to contraction of the gallbladder. The gallbladder empties when fat is present in the stomach and symptoms usually occur several hours after eating. Pain would likely be present in the region of the gallbladder.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

A client with acute interstitial pancreatitis has laboratory values that show mild hypocalcemia. The nurse knows that this condition occurs in pancreatitis due to

A) Elevated amylase.

B) Poorly digested fats.

C) Vomiting.

D) Decreased food intake.

Answer: B

B) Fats are incompletely metabolized in pancreatitis. Because calcium ions are bound to the fats, hypocalcemia can occur.

NP:AN; CN:PH; CA:M

Topic: Physiological Integrity

A 3-year-old's parents are unable to "room in" because of other responsibilities at home. During painful hospital procedures, the nurse observes that the child becomes very quiet and never cries. Based on knowledge of growth and development, the nurse would interpret this behavior as evidence that he

A) Does not feel well.

B) Has been taught not to misbehave in front of strangers.

C) Has given up fighting and has become despondent and hopeless.

D) Was well prepared by his parents for the separation and hospitalization.

Answer: C

C) A toddler who passively accepts aggressive, painful intrusions into his or her life has usually given up any sense of hope and is suffering from separation anxiety. He is depressed and requires specialized care from the staff and parents.

NP:AN; CN:H; CA:P

Topic: Health Promotion and Maintenance

A client's demand pacemaker is programmed for a ventricular rate of 72. When the nurse takes the client's apical pulse, it is 84 and regular. The nursing action is to

A) Obtain a cardiogram.

B) Place the client on bedrest.

C) Report this finding immediately.

D) Do nothing more at this time.

Answer: D

D) A demand pacemaker stimulates cardiac contraction when the heart rate falls below the preset rate. A regular rate that is above the demand rate and below 100 indicates that the client's heart is beating independently at a normal sinus rate; therefore, no action is called for at this time.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

The nurse observes another nurse enter the room of a blind client without announcing herself. The appropriate intervention is to

A) Do nothing, as there is no intervention required.

B) Tell the nurse that she had always learned to announce herself when entering the room of a blind person.

C) Tell the client she is sorry the other nurse may have frightened her.

D) Inform the head nurse so that he can intervene.

Answer: B

B) Because the nurse's behavior is not therapeutic and may cause the client to be frightened, explaining how she herself learned to approach a blind client is a way of teaching the other nurse a new approach.

NP:I; CN:S; CA:M

Topic: Safe, Effective Care Environment

A male client has just returned from a bronchoscopy procedure to diagnose possible bronchogenic carcinoma. The critical nursing assessment immediately following the test is to assess for

A) Vital signs to compare with baseline signs.

B) The client's face and neck for edema.

C) The client's ability to deep breathe and cough.

D) Signs of dyspnea or wheezing.

Answer: D

D) Dyspnea and wheezing are signs of laryngeal edema or bronchospasm which can result in respiratory distress and must be reported to the physician immediately. Clients are instructed to refrain from coughing which could result in hemorrhaging. His face and neck should be assessed for subcutaneous crepitus, not just edema. Vital signs are always important to monitor, but at this time the most crucial assessment is to monitor for respiratory problems.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

In teaching a newly diagnosed diabetic client about insulin self-injection, the nurse teaches that the injection site currently believed to be the best, because it provides the most rapid insulin absorption, is the

A) Arms.

B) Thighs.

C) Abdomen.

D) Buttocks.

Answer: C

C) Studies have shown that insulin is most rapidly and consistently absorbed from the subcutaneous tissue of the abdomen. The current thinking, therefore, is that insulin injections should be rotated among sites on the abdomen alone (with the exception of 1 inch around the umbilicus), rather than among the other available anatomic sites, i.e., arms, thighs and buttocks.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

As part of a newborn assessment, the nurse knows that signs of hypoglycemia in the infant include

A) Hyperactivity, high-pitched cry, respiratory distress.

B) Twitching, shrill or intermittent cry.

C) Stuporlike behavior, no cry.

D) Weak, soft cry.

Answer: B

B) Infants with signs and symptoms of hypoglycemia usually have a shrill or intermittent cry and may have hypertonicity. Answer (A) refers to an infant born to a drug-addicted mother.

NP:A; CN:H; CA:MA

Topic: Health Promotion and Maintenance

In which situation would gloves not be necessary when caring for an AIDS client?

A) When in contact with urine.

B) Changing an ostomy pouch.

C) Monitoring an IV infusion.

D) When suctioning clients.

Answer: C

C) The first three situations could result in transmission of the HIV virus. Starting an IV would require gloves, but monitoring an infusion, a closed system, would not.

NP:P; CN:S; CA:M

Topic: Safe, Effective Care Environment

A 39-year-old client has been admitted to the hospital with clinical manifestations indicating acute renal failure. A precipitating factor seems to be a viral infection of the upper respiratory tract. Considering the diagnosis while completing a physical assessment, the nurse would expect to observe

A) Anuria, bradycardia, tachypnea.

B) Urine output of 400 mL/day, dyspnea, neck vein distention.

C) Urine specific gravity of 1.010, decreased creatinine levels, hypokalemia.

D) Hypomagnesemia, nausea, vomiting, weakness.

Answer: B

B) These signs are indicative of fluid overload due to decreased ability to excrete urine. When the end products of metabolism cannot be excreted in sufficient amounts, they will accumulate in the body. Resultant blood samples will indicate higher levels of creatinine, potassium and magnesium, not lower levels. When fluid overload occurs due to decreased urine output, the intravascular compartment becomes overloaded with fluids causing tachycardia and neck vein distention.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

A 6-month-old child with cystic fibrosis is brought to the hospital with sudden onset vomiting and abdominal distention. Intussusception is the admitting diagnosis. The nurse will anticipate that the child will first be prepared for

A) Total parenteral nutrition (TPN) supplement.

B) Barium enema x-ray.

C) Nasogastric (NG) tube insertion.

D) Abdominal surgery.

Answer: B

B) A barium enema is the first treatment of choice because this procedure frequently reduces the bowel and cures the intussusception (telescoping bowel). If this procedure does not work, surgery for bowel reduction will be done. The child will probably not require TPN or an NG tube.

NP:P; CN:PH; CA:P

Topic: Physiological Integrity

A client with a myocardial infarction is transferred to the transitional care unit as his condition improves. The nursing care plan will be based on knowledge that

A) It is necessary to limit visitors until his condition has improved.

B) It is therapeutic to give him explanations of his illness as soon as possible.

C) The client must begin to accept that changes in lifestyle will be needed.

D) It is important to eliminate stress as much as possible in his daily routine.

Answer: D

D) The first priority will be to minimize stress by orienting the daily routines to his needs. This may include his having visitors immediately, rather than limiting them.

NP:P; CN:PH; CA:M

Topic: Physiological Integrity

When a male client returns from the recovery room following a lumbar laminectomy, the most important postoperative assessment is to

A) Auscultate lung sounds.

B) Check the client's temperature for signs of infection.

C) Check for sensation in the lower extremities.

D) Observe the dressing for any drainage.

Answer: C

C) All of the interventions are important and will be carried out during the postoperative period; however, the most important intervention is to check for sensation. The ability to wiggle toes and move his feet indicate there is not a complication from the surgical site.

NP:A; CN:PH; CA:S

Topic: Physiological Integrity

After removing the fecal impaction, the client complains of feeling light-headed and the pulse rate is 44. The priority intervention is to

A) Place in shock position.

B) Call the physician.

C) Begin CPR.

D) Monitor vital signs.

Answer: A

A) The client requires treatment for shock. Vital signs are monitored after placing the client in the shock position; then the physician is called for orders.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

The nursing behavior of sitting down at the client's bedside to talk with the client will convey a sense of

A) Communication.

B) Empathy.

C) Sympathy.

D) Encouragement.

Answer: B

B) Nonverbal action conveys acceptance, openness to listen, and empathy. It assists the client to verbalize feelings.

NP:AN; CN:PS; CA:PS

Topic: Psychosocial Integrity

Which nursing diagnosis should receive the highest priority in a client with acute renal failure?

A) Altered nutrition: less than body requirements related to anorexia.

B) Activity intolerance related to fatigue and muscle cramps.

C) Fluid volume excess related to oliguria.

D) Risk for trauma related to decreased alertness.

Answer: C

C) The oliguria associated with acute renal failure results in fluid volume excess. The increase in fluid volume may produce life-threatening effects such as heart failure, hypertension, and cerebral edema. The other nursing diagnoses would have lower priority.

NP:P; CN:PH; CA:M

Topic: Physiological Integrity

A client with cystic fibrosis is receiving dornase-alfa (Pulmozyme). To assess for desired therapeutic effect, the nurse would monitor the client's

A) Weight.

B) Cardiac rhythm.

C) Lung sounds.

D) Serum chloride.

Answer: C

C) Dornase-alfa reduces the viscosity of the sputum in clients with cystic fibrosis. Pulmonary function is improved and the incidence of respiratory tract infections is lessened. Lung sounds reflect the presence or absence of lung congestion which may indicate infection and are, therefore, monitored closely as an indicator of the therapeutic effect of this drug.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

A client is brought to the hospital by her husband who says she is highly anxious and spends half the morning doing rituals. As part of her treatment plan, the client will join a daily group therapy session at 10:30 in the morning. The rationale for choosing this time of day is

A) Anxious clients are more relaxed in the morning.

B) Most groups are planned for the morning when physicians are on the unit.

C) Mornings are better for group therapy because clients have the rest of the day to work through problems that come up during the sessions.

D) The client will have just completed her ritualistic activity.

Answer: D

D) It is best to plan any activity, particularly therapy, to follow the compulsive activity because anxiety is lowest at this time.

NP:AN; CN:PS; CA:PS

Topic: Psychosocial Integrity

Following gall bladder surgery, a client has orders for an IV of D5W to run 100 ml/hour. When the nurse checks at the beginning of the evening shift, she observes that the IV is one hour behind. The appropriate action would be to

A) Increase the flow so that the loss is made up over the remaining hours in the shift.

B) Continue the IV flow at the same rate.

C) Double the rate of drops/minute for one hour to make up for the loss.

D) Speed up the IV to make up for the loss within the next hour.

Answer: A

A) The IV needs to be infused equally over the time ordered. When the IV is behind, it should be recalculated. The calculation is completed by taking the amount of solution remaining to be infused and dividing by the remaining hours.

NP:I; CN:PH; CA:S

Topic: Physiological Integrity

The development of anti-Rh antibodies within the mother could have been prevented with the administration of RhoGAM for previous pregnancies. The nurse's knowledge of RhoGAM is that it

A) Must be given on the sixth day postdelivery.

B) Should be given to an unsensitized mother after each pregnancy or abortion.

C) May be given to the infant in the uterus.

D) May be given even after sensitization occurs.

Answer: B

B) RhoGAM should be given after each pregnancy including an abortion, because fetal blood may enter the mother's circulation and set up a sensitization process.

NP:AN:CN:H; CA:MA

Topic: Health Promotion and Maintenance

The nurse will know that a client with chronic renal failure adheres to dietary phosphorus modification when he

A) Increases milk products.

B) Increases red meats.

C) Decreases whole grain products.

D) Decreases red vegetables.

Answer: C

C) Whole grain breads and cereals provide high sources of phosphate. Other sources include milk, meat, poultry, fish, and legumes. Hyperphosphatemia results from decreased renal clearance. Calcium antacids are often given to bind phosphate in the GI tract.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

When evaluating the client's understanding of a low potassium diet, the nurse will know he understands if he says that he will avoid

A) Pasta.

B) Raw apples.

C) French bread.

D) Dry cereal.

Answer: B

B) Raw apples are high in potassium, while white-enriched and French bread, dry cereal, and pasta are foods low in potassium.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

After an automobile accident in which the client sustained a head injury, a craniotomy has been scheduled. Analyzing the client's immediate postoperative needs, the nursing care plan includes

A) Maintaining fluid and electrolyte balance by administering at least 3000 mL D5 Lactated Ringer's every 24 hours.

B) Keeping his temperature below 97 degrees F to decrease metabolic needs.

C) Obtaining serial blood and urine samples.

D) Placing him in supine position.

Answer: C

C) Serial blood and urine samples are collected because sodium regulation disturbances frequently accompany head injury. The temperature should be kept normal to avoid increasing metabolic needs. At 97 degrees F, the client would probably shiver, causing not only increased intracranial pressure but also increased metabolic rate. Fluids are kept at a minimum to prevent overhydration, which can lead to cerebral edema.

NP:P; CN:PH; CA:S

Topic: Physiological Integrity

As the nurse is diluting an NG feeding for a CVA client, her husband says, "She's getting better, isn't she?" The best nursing response at this time is

A) "Why do you ask? Does she appear different to you?"

B) "The doctor could better tell you that."

C) "No. She is just about the same; but only time will tell."

D) "Her condition is stable and she is very ill."

Answer: A

A) The appropriate response is an assessment question to determine whether the husband has observed a change. All the other responses close off communication, thus are nontherapeutic.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

A client has an arteriovenous fistula as an access site for hemodialysis. Which assessment finding indicates that the fistula is patent?

A) Normal capillary refill distal to the fistula.

B) Palpation of a pulse distal to the fistula.

C) Absence of edema or redness over the fistula.

D) Auscultation of a bruit over the fistula.

Answer: D

D) The flow of blood through a patent arteriovenous fistula produces turbulence manifested by a bruit audible when the fistula is auscultated.

NP:AN; CN:PH; CA:M

Topic: Physiological Integrity

Following a client's total hip replacement, immediately postoperatively the nurse will formulate a goal that states

A) Turn on operative side only immediately postoperatively.

B) Operative leg maintained in abduction.

C) Head of bed elevated to 45-degree angle.

D) Buck's traction until hip can be put through range of motion.

Answer: B

B) The leg must be kept in abduction. This position prevents dislocation of the new hip until range of motion can be instituted. Buck's traction is no longer used following total hip replacement. Physicians now order that the client may be turned on either side postop.

NP:P; CN:PH; CA:S

Topic: Physiological Integrity

A client, age 32, is married and has no children. He has been experiencing abdominal pain for several months and his physician suspects a duodenal ulcer. Assessing the symptoms described by the client, the nurse will chart that the pain is

A) Constant over the epigastric area when eating.

B) Intermittent with no correlation between food intake and when the pain occurs.

C) Experienced about 30 minutes after eating regardless of the diet.

D) Experienced about 2 to 3 hours after eating.

Answer: D

D) Pain is reduced upon eating when the client has a duodenal ulcer. When the duodenum is empty, about 2 to 3 hours after eating, the pain recurs.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

A client with COPD has orders for oxygen administration. The method that delivers the appropriate liter flow and concentration of oxygen would be

A) A venturi mask.

B) An oxygen catheter.

C) Nasal prongs.

D) A mask with reservoir bag.

Answer: A

A) The venturi mask delivers a fixed FIO2, usually 24 to 35% at a liter flow of 2 to 8 l. The COPD client must have an accurate and predictable FIO2 and a low liter flow (less than 6 l/minute) to prevent hypoxemia. A liter flow of 8 to 10 will provide an FIO2 of 70 to 100%. The reservoir bag contains the highest level of oxygen. As the client inhales, oxygen is taken in from the bag.

NP:P; CN:PH; CA:M

Topic: Physiological Integrity

A hypothyroid client has orders for all of the following medications. The nurse would evaluate the client most closely following administration of which medication?

A) Meperidine (Demerol).

B) Levothyroxine (Synthroid).

C) Digoxin (Lanoxin).

D) Ibuprofen (Motrin).

Answer: A

A) Hypothyroidism reduces the metabolic rate and prolongs the sedative effects of medications. Narcotics, such as meperidine, are especially dangerous and should be given in smaller doses. The client must be closely monitored for signs of oversedation and respiratory depression.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

The nurse is assigned to a client with a central vein IV infusing hyperalimentation solution. The most important nursing intervention is

A) Checking urine specific gravity, sugar, and acetone every 4 hours.

B) Preparing the next bottle of solution prior to use.

C) Changing the IV filter and tubing with each bottle change.

D) Maintaining the exact amount of solution administered hourly by adjusting the flow rate.

Answer: A

A) Checking the urine for glucose and acetone is essential to prevent a hyperosmolar condition. Insulin may have to be administered according to rainbow coverage. Notify physician for urine glucose over 2+ and positive acetone.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

The nurse is counseling a woman who has just learned she is pregnant. She says she does not want to gain too much weight because her husband likes her "thin." The most appropriate response is

A) "Why don't you have your husband come to the clinic next time, and we can all talk about nutrition."

B) "If you are careful about the foods you eat, especially those high in calories, you will not gain too much."

C) "It's best for the baby if you don't try to stay too thin."

D) "Let's talk about the importance of good nutrition and weight gain in pregnancy."

Answer: D

D) Adequate nutrition and weight gain in pregnancy are directly related to decreased mortality and morbidity in the newborn. Helping the client understand the role of nutrition and weight gain will help her then explore the best way to talk to her husband about his concerns.

NP:I; CN:H; CA:MA

Topic: Health Promotion and Maintenance

Adequate nutrition is essential during early pregnancy for optimum fetal development. The nurse, in counseling a client, would recommend a daily diet that would include

A) 1500 calories

B) One fruit or vegetable high in vitamin C.

C) Low roughage foods.

D) A low sodium diet.

Answer: B

B) The diet must include at least one fruit or vegetable high in vitamin C, and should include a total of four fruits and vegetables. Pregnancy requires the addition of 300 calories a day over regular caloric intake, and 1500 calories a day would be inadequate. The recommended calories for someone age 28 are 2300 a day. Research indicates that sodium is essential during pregnancy.

NP:I; CN:H; CA:MA

Topic: Health Promotion and Maintenance

A client in her 37th week of pregnancy is showing early signs of pre-eclampsia. The nursing care plan will include assessment for further signs of this condition. Indications of progression of pre-eclampsia to a more severe state would be the presence of

A) Severe hypertension, glycosuria, polyuria.

B) Hypertension, weight loss, diuresis.

C) Hyperreflexia, oliguria, epigastric pain.

D) Hypertension, convulsions, polyuria.

Answer: C

C) Hyperreflexia occurs with increased CNS irritation. Epigastric pain is usually due to edema or bleeding into the liver capsule and oliguria. Other signs include edema and hypertension.

NP:A; CN:H; CA:MA

Topic: Health Promotion and Maintenance

When a client with a diagnosis of manic episode returns to the clinic to have lithium blood levels checked, her lithium level is only slightly higher than the previous week but she complains of blurred vision and ataxia. The first intervention is to

A) Withhold the next dose.

B) Suggest she drink more fluid.

C) Instruct her to watch for signs of toxicity.

D) Notify the physician.

Answer: A

A) These are symptoms of toxicity and the nurse must withhold the next dose. The nurse would then notify the physician. The client needs to maintain a normal fluid level to prevent toxicity, but this may not be the cause of her symptoms.

NP:I; CN:PS; CA:PS

Topic: Psychosocial Integrity

A nursing intervention to increase the nutritional status of a client on chemotherapy is to

A) Encourage the intake of fluids with meals.

B) Provide the highest amount of protein with the morning meal.

C) Provide three meals a day and high protein supplement fluids at least twice a day.

D) Use high protein supplement fluids as the major source of protein during the chemotherapy.

Answer: B

B) The highest amount of protein should be ingested in the morning because this is usually when the appetite is better. The client should consume at least one-third of the daily protein requirement with this meal. It is best to offer frequent small meals or snacks throughout the day to promote adequate protein consumption. Fluids should be taken between rather than with meals to prevent the client from feeling full.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

A schizophrenic client has been taking Thorazine for 2 days and is beginning to develop extrapyramidal effects. The nurse would expect the physician to order

A) Xanax.

B) Cogentin.

C) L-dopa.

D) The drug to be discontinued.

Answer: B

B) Cogentin is an antiparkinson drug and will reduce these side effects. Xanax is an antianxiety drug. L-dopa is given to clients with Parkinson's disease but is not useful for dystonic effects; answer (D) is not the treatment of choice, because the client needs Thorazine to control her symptoms.

NP:P; CN:PS; CA:PS

Topic: Psychosocial Integrity

The toy most suitable to provide for a 21 1/2 year old hospitalized for diarrhea is

A) A stuffed animal.

B) A mobile.

C) Play -doh.

D) A box of jacks.

Answer: A

A) A stuffed animal would not be harmful and it would be comforting. Play-doh is more appropriate for older children. Jacks are not safe for an infant; they will go immediately into the infant's mouth.

NP:P; CN:H; CA:P

Topic: Health Promotion and Maintenance

A young male client has had a cast placed on his right leg. While caring for the client, the nurse identifies a "hot spot" or area on the cast that feels warm. The nurse reports to the physician the signs of

A) Infection.

B) Uneven cast drying.

C) Poor circulation.

D) The cast being too tight.

Answer: A

A) Infection can be identified by "hot spots," or areas on the cast that feel warm to the touch. A hot spot is not evidence of poor circulation or too tight a cast.

NP:I; CN:PH; CA:S

Topic: Physiological Integrity

The nursing staff should encourage clients with senile dementia to participate in activities that provide him a chance to

A) Learn something new.

B) Compete with others for stimulation.

C) Get a sense of continuity.

D) Complete a task and feel successful.

Answer: D

D) It is essential that the client participate in activities that he can complete and that will increase his self-esteem. His diagnosis indicates he will have difficulty learning anything new (A) and competition would be too threatening (B). If his diagnosis is dementia, continuity will not be an issue.

NP:P; CN:PS; CA:PS

Topic: Psychosocial Integrity

Assisting the physician to establish a CVP line in a client, the nurse instructs the client to exhale against a closed glottis (perform Valsalva's maneuver). The purpose of this procedure is to

A) Decrease intrathoracic pressure.

B) Establish equal pressure in the line.

C) Prevent an air embolism.

D) Assist in catheter insertion.

Answer: C

C) Valsalva's maneuver--the attempt to forcibly exhale with the glottis, nose and mouth closed--produces increased intrathoracic pressure and lessens the chance of an air embolism as the CVP catheter is inserted.

NP:AN; CN:PH; CA:M

Topic: Physiological Integrity

The nurse is monitoring the following cardiac rhythms on the central cardiac monitoring console on the unit. Which client would the nurse assess first?

A) Complete heart block.

B) Ventricular tachycardia.

C) Sinus arrhythmia.

D) Atrial fibrillation.

Answer: B

B) Ventricular tachycardia is a life-threatening arrhythmia because it severely limits cardiac output and can degenerate quickly into ventricular fibrillation. Although atrial fibrillation and complete heart block can limit cardiac output, they are not as immediately life-threatening as is ventricular tachycardia. Sinus arrhythmia is not life-threatening.

NP:A; CN:PH; CA:M

Topic: Physiological Integrity

The physician has ordered a cholecystogram for a client. The intervention most important as a part of the preparation for this procedure is

A) Giving the client a high-fat meal.

B) Assessing for shellfish allergy.

C) Administering an enema.

D) Allowing a light breakfast.

Answer: B

B) If the client is allergic to shellfish, he most likely will be allergic to the dye used for the cholecystogram. Answers (C) and (D) might be carried out, but they are not the most important.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

A client is receiving the drug flecainide (Tambocor). Which nursing intervention should be implemented?

A) Assess blood glucose by finger-stick AC and HS.

B) Give the medication with meals.

C) Monitor apical pulse rate and rhythm.

D) Restrict intake of high sodium foods.

Answer: C

C) Flecainide is an antiarrhythmic used for the treatment of certain life-threatening arrhythmias. The apical pulse is monitored to evaluate the therapeutic response to the drug and to detect any new arrhythmias which may represent a side effect or toxic effect of this potent drug.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

When a child has had one poison ingestion, statistically he is nine times more likely to have another poisoning episode within the year. To prevent further poisoning incidents, the most important information to tell the mother is to

A) Keep purses out of the child's reach.

B) Never give medications to others in front of the child.

C) Keep all cabinets locked at all times.

D) If poisoning occurs, do as the label on the bottle recommends.

Answer: C

C) Answers (A) and (B) are also necessary information but keeping cabinets locked is critical. Not all labels include sufficient information. The child's mother should be given the telephone number of a poison control center.

NP:I; CN:PH; CA:P

Topic: Physiological Integrity

A client complains of nausea and loss of appetite. The monitor reveals she is now in a slow atrial fibrillation with a pulse rate of 72. The Digoxin dose is 0.25 mg PO daily with Valium and Compazine ordered prn. The initial nursing intervention will be to

A) Administer the Compazine ordered prn for nausea.

B) Call the physician because the client is probably having an allergic reaction to Digoxin.

C) Administer the Valium ordered prn for anxiety.

D) Hold the drug as the client is probably Digoxin-toxic.

Answer: D

D) One of the first signs of Digoxin toxicity is nausea. The drug should not be given until the cause of the client's nausea is determined. Neither Valium nor Compazine is indicated until the source of the nausea is determined.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

A female client is placed on digoxin (Lanoxin) 0.25 mg daily. Two weeks later, she comes to the clinic for a check-up. If the medication is effective, the nurse will assess a

A) Lowered blood pressure.

B) Decreased pulse rate.

C) Decreased urine output.

D) Decreased respiratory rate.

Answer: B

B) The pulse rate should decrease with digoxin due to strengthened myocardial contraction. Urine output should increase. Blood pressure and respirations will be unaffected.

NP:E; CN:PH; CA:M

Topic: Physiological Integrity

A 6-week-old infant with a diagnosis of a fever of unknown origin is admitted to the unit. The nurse enters the room and finds him sleeping. A priority assessment on admission is to obtain his vital signs. The nurse would begin this assessment by

A) Taking his axillary temperature.

B) Counting his respirations.

C) Taking his rectal temperature.

D) Taking his apical pulse.

Answer: B

B) Counting respirations before disturbing the child will give the most accurate number. As soon as a child is touched (or even approached, if awake) his respiratory and apical rate will increase. Take respirations first, apical pulse next, and rectal temperature last.

NP:A; CN:PH; CA:P

Topic: Physiological Integrity

As the nurse is changing an abdominal dressing, the client suddenly coughs and an evisceration of the wound occurs. The priority intervention is to

A) Obtain vital signs.

B) Keep the client in a supine position.

C) Apply an abdominal binder to the incision.

D) Apply butterfly tape to the wound edges.

Answer: B

B) The client's wound opens and the bowel contents protrude when an evisceration occurs. Intra-abdominal pressure changes creating a shock state; thus the supine position is required. In addition, the bowel contents should be prevented from protruding any further.

NP:I; CN:PH; CA:S

Topic: Physiological Integrity

A client is to receive IV heparin at a rate of 1200 units per hour. Available is a bag containing 25,000 units of Heparin in 500 mL of D5W. The nurse would set the IV controller to deliver

A) 48 mL per hour.

B) 24 mL per hour.

C) 82 mL per hour.

D) 12 mL per hour.

Answer: B

B) This computation can be done using the formula of D divided by H multiplied by V. 1200 divided by 25,000 multiplied by 500 equals 24 mL.

NP:I; CN:PH; CA:MA

Topic: Physiological Integrity

A client has been admitted to an inpatient psychiatric unit. Her initial diagnosis is schizophrenia--undifferentiated type. When the nurse is sitting with the client, she says slowly, "My blue sky moves to arm." This statement is most clearly an example of

A) Hallucinatory experience.

B) Associative looseness.

C) Neologism.

D) Flight of ideas.

Answer: B

B) Schizophrenics often evidence loose associations or disordered thoughts. This is manifested by words that don't make sense, word salad, and neologisms (made up words). Flight of ideas is found with manic disorders.

NP:AN; CN:PS; CA:PS

Topic: Psychosocial Integrity

A client in acute intoxication or DTs is admitted to the emergency room. According to standard orders, the nurse will probably add which specific supplement to the IV glucose?

A) Calcium gluconate.

B) Vitamin B, thiamine.

C) Vitamin C.

D) Magnesium sulfate.

Answer: B

B) The most critical supplement is vitamin B, specifically thiamine, although often a B complex (mixture that contains all B vitamins) is given. This vitamin deficiency is at least partially responsible for causing the client to develop Delirium Tremens. None of the other answers is relevant.

NP:P; CN:PH; CA:PS

Topic: Physiological Integrity

Paralytic ileus is a frequent complication of postoperative abdominal surgery. According to the physician's orders and the nurse's assessment, a planned intervention would be to

A) Administer PO fluids only.

B) Insert a nasogastric tube.

C) Listen for bowel sounds.

D) Insert a rectal tube.

Answer: C

C) The client will not be fed until bowel sounds are present, abdominal distention relieved, and flatus is passed. Answer (C) would be the first intervention followed by (B) and (D) if necessary.

NP:I; CN:PH; CA:S

Topic: Physiological Integrity

While assessing a client in skeletal traction, the nurse observes the distal extremity to be pale with slow capillary refill and palpated at a 1+ pulse. The initial intervention is to

A) Assess the client every 15 minutes for changes.

B) Remove the traction.

C) Observe for ecchymosis or signs of infection.

D) Notify the physician.

Answer: D

D) There is a circulatory compromise and thus the physician needs to be notified immediately. The other actions, except removing traction, will be carried out later.

NP:I; CN:PH; CA:M

Topic: Physiological Integrity

When a client has the diagnosis of schizophrenia, the most conspicuous signs of tardive dyskinesia are

A) Muscular spasms of the extremities.

B) Drowsiness and lethargy.

C) Spastic movements of the eyelids.

D) Oral movements and drooling.

Answer: D

D) Drooling, shuffling gait, and general dystonic symptoms are characteristic of tardive dyskinesia, a condition associated with long-term use of antipsychotic drugs. This is usually a permanent form of an extrapyramidal effect. Muscular spasms most often occur with dystonia, a side effect that occurs early in the use of antipsychotics.

NP:A; CN:PS; CA:PS

Topic: Psychosocial Integrity

When taking the history from the mother of a baby who has pyloric stenosis, the nurse would expect her to say that the baby vomits

A) When new foods are introduced.

B) Between feedings.

C) Immediately after feedings.

D) Continuously.

Answer: C

C) Stenosis of the pyloric sphincter impedes gastric emptying; therefore, feedings are vomited when the stomach is full.

NP:A; CN:PH; CA:P

Topic: Physiological Integrity

Following abdominal surgery it is important that the nurse assess the client for negative nitrogen balance. The clinical manifestation most indicative of negative nitrogen balance is

A) Dehydration.

B) Generalized edema.

C) Diarrhea.

D) Pale color to skin.

Answer: B

B) When there is insufficient nitrogen for synthesis, there is a change in the body's osmotic pressure resulting in the oozing of fluids out of the vascular space. This phenomena results in the formation of edema in the abdomen and flanks.

NP:AN; CN:PH; CA:S

Topic: Physiological Integrity

The RN responsible for administering a thiazide medication to a client evaluates his recent lab reports, which are K+ 3.0 and NA+ 140. The correct intervention is to

A) Administer the thiazide drug.

B) Withhold the drug and report both lab results to the physician.

C) Notify the physician.

D) Withhold the drug and report K+ level to the physician.

Answer: D

D) The appropriate intervention is to withhold the thiazide medication until the nurse receives further orders and report K+ level to the physician. Normal K+ is 3.5 to 5.5 mEq/l. His NA+ level is normal (range 135 to 145 mEq/l).

NP:I; CN:PH; CA:M

Topic: Physiological Integrity


1 comment:

Sharon said...

Hi,

My name is Sharon Ray and I am the assistant editor of Cysticfibrosis.net. I am contacting you today in hopes of developing a relationship with your website; we have seen your site and think your content is great. Cysticfibrosis.net offer a free informational resource to both the general and professional public on this terrible disease.

I hope you show some interest in building relationship, please contact me at sharon.cysticfibrosis.net@gmail.com.

Bubble Shooter


SIGN IN OUR GUESTBOOK ;-)