NCLEX Reduction of Risk Potential Questions
Reduction of Risk Potential NCLEX Practice Questions
Question 1.
"fine nurse is caring for a client with seizure disorder. Which statement regarding seizure precautions is correct?
(a) Padded tongue blades should be at the bedside.
(b) Oxygen and suctioning should be at the bedside.
(c) Padding bed rails with blankets can help prevent injury.
(d) Restraint mitts will help keep the client from removing tubes or IVs.
Answer:
(b) Oxygen and suctioning should be at the bedside.
Rationale:
Oxygen and suctioning are key to maintain the client's airway. Forcing a tongue blade into someone's mouth may chip teeth and cause aspiration of tooth fragments. Improper placement of a tongue blade can block the airway. Padding the bed rails may embarrass the client and family, and bed rails may be considered restraint in some facilities. A safer option would be to place a mattress on the floor. Restraint mitts should not be used on this client as there is no other indicated need for the mitts, and clients should be treated using the least restrictive means possible.
Question 2.
The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?
(a) hypoxemia and hypocarbia
(b) hyperoxemia and hypocarbia
(c) hypoxemia and hypercarbia
(d) hyperoxemia and hypercarbia
Answer:
(c) hypoxemia and hypercarbia
Rationale:
As COPD worsens, blood oxygen levels decrease (hypoxemia) and carbon dioxide increases (hypercarbia). Options 1, 2, and 4 do not reflect the expected ABG results.
Question 3.
The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?
(a) Eschar is present on at least part of the wound.
(b) Full-thickness skin loss is present with undermining.
(c) Partial-thickness skin loss of the epidermis is present.
(d) The area is red and does not blanch with external pressure.
Answer:
(b) Full-thickness skin loss is present with undermining.
Rationale:
Eschar on at least part of the wound indicates a stage 4 wound. Partial-thickness skin loss is found in stage 2 wounds. Areas that are red and do not blanch with external pressure are stage 1 wounds.
Question 3.
The nurse is caring for a client who just returned from a total hip arthroplasty. A student nurse is helping provide care for this client. Which action by the student nurse requires intervention by the nurse?
(a) The student nurse floats the client's heels with a pillow.
(b) The student nurse positions the client with the legs adducted.
(c) The student nurse applies the sequential compression device (SCD) per orders.
(d) The student nurse encourages deep breathing and incentive spirometer use every 2 hours.
Answer:
(b) The student nurse positions the client with the legs adducted.
Rationale:
The client should be positioned with the legs abducted using a pillow or splint. Floating the client's heels is appropriate to prevent skin breakdown. Application of SCDs reduces the risk of venous thromboembolism. Deep breathing and incentive spirometer use help prevent respiratory complications.
Question 4.
The nurse is caring for a homeless client brought to the emergency department with a diagnosis of heat stroke. Which key features of heat stroke would the nurse expect to note upon assessment? Select all that apply.
(a) a body temperature of 10(d)2°F
(b) heart rate of 116 and blood pressure of 78/52
(c) heart rate of 49 and blood pressure of 152/90
(d) heart rate of 120 and respiratory rate of 9 breaths per minute
(e) blood pressure of 82/48 and respiratory rate of 26 breaths per minute
Answer:
(a) a body temperature of 10(d)2°F
(b) heart rate of 116 and blood pressure of 78/52
(e) blood pressure of 82/48 and respiratory rate of 26 breaths per minute
Rationale:
Clients with heatstroke have a body temperature of greater than 104°F. Tachycardia, hypotension, and tachypnea are other expected findings in heat stroke.
Question 5.
A college student presents at the emergency department after being thrown off a horse. Head injury with increased intracranial pressure (ICP) is suspected. The nurse understands that late signs of increased ICP include which manifestations? Select all that apply.
(a) seizures
(b) irritability
(c) restlessness
(d) disorientation
(e) severe headache
(f) nausea and vomiting
Answer:
(a) seizures
(e) severe headache
(f) nausea and vomiting
Rationale:
Late signs of increased ICP include seizures, severe headache, and nausea and vomiting (often projectile). Irritability, restlessness, and disorientation are early signs of increased ICP.
Question 6.
The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?
(a) "I should void before and after intercourse."
(b) "I should wear loose-fitting cotton underwear."
(c) "I can continue using spermicide for birth control."
(d) "If I have burning when I urinate, I will contact my physician."
Answer:
(c) "I can continue using spermicide for birth control."
Rationale:
Spermicides can increase the risk of cystitis and another form of birth control should be used if possible. Voiding before and after intercourse minimizes the risk of bacteria being introduced into the urethra. Loose-fitting cotton underwear helps prevent irritation to the area. Burning upon urination may indicate another infection and should be assessed by the health care provider for diagnosis and treatment.
Question 7.
A client in the emergency department is complaining of abdominal pain after an episode of nausea and vomiting. Which statement by the client to the nurse necessitates prompt notification of the health care provider?
(a) "I started hurting when I got up this morning to go to work."
(b) "My grandmother had to have her appendix out many years ago."
(c) "I haven't eaten anything because I've been so nauseated and throwing up."
(d) "The pain is worse when I cough or move but feels better when I bend my right hip."
Answer:
(d) "The pain is worse when I cough or move but feels better when I bend my right hip."
Rationale:
Abdominal pain that increases with cough or movement and is relieved by bending the right hip or knees indicates perforation and peritonitis. Untreated peritonitis can be life-threatening. Pain is a common finding in appendicitis and other inflammatory bowel problems. Family history can play a part in the risk of abdominal alterations. Nausea and vomiting are common findings.
Question 8.
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
(a) inspection, auscultation, palpation, percussion
(b) inspection, palpation, percussion, auscultation
(c) inspection, percussion, auscultation, palpation
(d) inspection, percussion, palpation, auscultation
Answer:
(a) inspection, auscultation, palpation, percussion
Rationale:
The correct order is inspection, auscultation, palpation, percussion. Abdominal assessment varies slightly from other assessments in that auscultation is performed before palpation or percussion in order to avoid changing the intensity and frequency of bowel sounds.
Question 9.
The nurse is caring for a client who has just returned from the cardiac catheterization lab. Which complications of cardiac catheterization require immediate intervention by the nurse?
Select all that apply.
(a) chest pain
(b) decreased appetite
(c) difficulty swallowing
(d) hematoma formation
(e) decreased pulses in the affected extremity
Answer:
(a) chest pain
(c) difficulty swallowing
(d) hematoma formation
(e) decreased pulses in the affected extremity
Rationale:
Chest pain, hematoma formation, and decreased pulses are signs of cardiac ischemia. The nurse should call the Rapid Response Team or health care provider immediately. Difficulty swallowing may indicate possible stroke. A decreased appetite is not a complication of cardiac catheterization and does not require emergent care.
Question 10.
The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?
(a) checking for an intact catheter tip
(b) washing the hands and donning gloves
(c) charting the client's tolerance to the procedure
(d) removing catheter slowly using the dominant hand
(e) holding pressure on the site until hemostasis is achieved
Answer:
(b) washing the hands and donning gloves
Rationale:
Before touching the client, the nurse should wash her hands and don gloves for protection from blood or other body fluids. While all of the other steps are part of the procedure, safety against blood-borne pathogens is the priority.
Question 11.
The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?
(a) an elderly client who is up to the chair for meals with assistance
(b) a 24-year-old client with diabetes whose hemoglobin A1C is (f)4%
(c) a client who is legally blind and lives independently, except for driving
(d) a client with severe right-sided weakness from a stroke and residual peripheral neuropathy
(e) a client who had a right pneumothorax and has a chest tube and can reposition independently
Answer:
(d) a client with severe right-sided weakness from a stroke and residual peripheral neuropathy
Rationale:
A client with severe weakness on one side will have difficulty turning and repositioning without assistance and will require turning and skin assessment every 2 hours. Neuropathy affects the client's ability to feel pain and causes damage to the skin to be less apparent to the client. An elderly client who can get up with assistance has more mobility than one with weakness and neuropathy.
Younger clients tend to be at lower risk of skin breakdown, and although this client has diabetes, his hemoglobin A1C reflects well-controlled blood sugars. Being blind is not necessarily a risk factor for skin breakdown, especially in the client who is able to live independently. Although the client with the chest tube may have diminished mobility, the ability to reposition independently minimizes the risk of skin breakdown from lying in one position too long.
Question 12.
The nurse is teaching a client and her family about home care following a laryngectomy. Which statement by the client indicates a need for further teaching from the nurse?
(a) "I will purchase a Medic-Alert bracelet."
(b) "I can wear loose-fitting turtlenecks to cover the stoma."
(c) "I can resume water aerobics once my doctor says it is okay."
(d) "I have a lot of green houseplants year-round throughout my home."
Answer:
(c) "I can resume water aerobics once my doctor says it is okay."
Rationale:
Swimming should be avoided and care should be taken when shaving or showering. A Medic-Alert bracelet is useful in life-threatening situations. Loose-fitting, high-neck sweaters and shirts may be worn to cover the stoma or tracheostomy tube. Green houseplants help increase humidity. Clients may also increase the humidity by using saline in the stoma as ordered, sitting pans of water around the house, or using a humidifier. Low humidity may make it more difficult to breathe and cause crusting around the stoma.
Question 13.
A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?
(a) "Pitting edema is the best indicator of fluid overload."
(b) "The client may have distended veins in the hands and neck."
(c) "I may hear moist crackles in the lungs during my respiratory assessment."
(d) "The client may need drug therapy and sodium restriction to treat the overload."
Answer:
(a) "Pitting edema is the best indicator of fluid overload."
Rationale:
Rapid weight gain is the best indicator of fluid excess, because visible signs of fluid overload may not be present. Fluid overload often results in distended veins in the hands and neck and moist crackles in the lungs. A combination of diuretics and nutrition therapy, including fluid and sodium restrictions, is the treatment for fluid overload.
Question 14.
The nurse is teaching a newly admitted client about fall prevention. The nurse understands that which of the following interventions can help prevent client falls? Select all that apply.
(a) keep personal articles within reach
(b) explain the use of the call light system
(c) keep the bed in the lowest position with all side rails up
(d) dim the room lights so that the client can get adequate rest
(e) remind the client to call for assistance when getting out of bed
Answer:
(a) keep personal articles within reach
(b) explain the use of the call light system
(e) remind the client to call for assistance when getting out of bed
Rationale:
Keeping personal articles within reach minimizes the risk of the client leaning out of bed to retrieve items. The client must understand how to use the call button, and the nurse should secure it to the bed within easy reach. The nurse should remind the client to call for assistance when he needs to get up and before he has an urgent need to go to the restroom. Some clients wait until they need to use the restroom and then try to hurry out of bed, increasing the risk of falls.
Use of all four bed rails is a form of restraint, and agency policy should be followed regarding their use. Dimming the room lights makes it more difficult to see and increases the fall risk. Use of safety lights under the bed or nightlighfs reduces the risk of falls.
Question 15.
The nurse is caring for a client in the cardiac unit and notices the client's rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?
(a) call a code blue
(b) check the client and check the leads
(c) initiate CPR while waiting on help to arrive
(d) prepare to start the client on a diltiazem (Cardizem) drip
(e) clear the room of unnecessary items to allow room for the crash cart and team
Answer:
(b) check the client and check the leads
Rationale:
The priority with any dysrhythmia is to check the client and the leads first to ensure that the client is truly having a rhythm change. Improperly placed or loose leads can mimic dysrhythmias; coughing or movement can create artifacts. Ventricular fibrillation is a life-threatening emergency; once the client is checked, the nurse should immediately call a code and initiate CPR when the backboard arrives. While waiting on the crash cart, the client should be positioned flat with the rails down for access.
If the client is not intubated, pull the bed away from the wall for the anesthetist. The room should be cleared of furniture or other items that will crowd the room. Diltiazem is given in cases of supraventricular tachycardia and is not part of the ACLS protocol for treatment of ventricular fibrillation. Drugs are given only after shocking the client to stabilize the rhythm and improve cardiac output.
Question 16.
The nurse is teaching a group of student nurses about radiation therapy. Which would the nurse include in the teaching? Select all that apply.
(a) The dose is always more than the exposure.
(b) Clients receiving brachytherapy are radioactive.
(c) Clients receiving teletherapy are not radioactive.
(d) Beta particles are the most common type of radiation therapy.
(e) Bodily waste from a client receiving brachytherapy does not require special handling.
Answer:
(b) Clients receiving brachytherapy are radioactive.
(c) Clients receiving teletherapy are not radioactive.
Rationale:
Clients undergoing brachytherapy have radioactive isotopes inside the body and are radioactive and potentially hazardous to others. Their bodily wastes are radioactive and require special handling until the isotope is completely eliminated from the body. Teletherapy uses a source of radiation outside the body; therefore, these clients are not radioactive. The dose is always less than the exposure because of energy loss on the way to the target tissue. Gamma rays are most commonly used for radiation due to their ability to deeply penetrate tissues.
Question 17.
A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?
(a) failure to track with the eyes
(b) crying without tear production
(c) bruising to the arms and shoulders
(d) greater-than-expected head circumference and bulging fontanels
Answer:
(d) greater-than-expected head circumference and bulging fontanels
Rationale:
Greater-than-expected head circumference and bulging fontanels are a finding of shaken baby syndrome due to subdural brain hemorrhage. An infant at 2 months does not yet track with the eyes. Crying is not a typical sign of shaken baby syndrome. External signs of abuse are usually absent; retinal hemorrhage is revealed on ophthalmoscopic examination. The nurse is legally obligated to report all cases of suspected child abuse or neglect.
Question 18.
The nurse is evaluating clients for risk of heparin-induced thrombocytopenia (HIT). Which client is at greatest risk for HIT, based on the nurse's assessment?
(a) a male client who just completed a 1 -week course of heparin
(b) a male client taking enoxaparin for management of unstable angina
(c) a female client receiving heparin for postsurgical thromboprophylaxis
(d) a female client taking enoxaparin to prevent clots following a mild myocardial infarction
Answer:
(c) a female client receiving heparin for postsurgical thromboprophylaxis
Rationale:
Increased risk factors for HIT include being female and heparin use as postsurgical thromboprophylaxis. HIT is more common in clients who have been on unfractionated heparin or who have used heparin for longer than 1 week. Enoxaparin is a low-molecular weight heparin, which carries a lower risk of developing HIT. It is often prescribed for clients with unstable angina to help increase blood flow through the heart.
Question 19.
The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
(a) RSS 1
(b) RSS 2
(c) RSS 3
(d) RSS 4
(e) RSS 5
(f) RSS 6
Answer:
(c) RSS 3
Rationale:
The client who responds quickly, but only to commands has a Ramsay score of 3. The client with an RSS of 1 is restless, anxious, or agitated. Clients with an RSS of 2 are alert, oriented, and cooperative. Clients with an RSS of 4 respond briskly to stimulus. A client with a sluggish response to stimulus is scored as a 5. A client with an RSS of 6 is deeply sedated and does not respond to stimulus.
Question 20.
The nurse is caring for a client who has a lithium level of (b)2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
(a) prepare to administer IV fluids
(b) notify the health care provider
(c) order a mechanical soft diet for the client
(d) administer the next dose of lithium when it is due
(e) observe the client for confusion and slurred speech
Answer:
(a) prepare to administer IV fluids
(b) notify the health care provider
(e) observe the client for confusion and slurred speech
Rationale:
Lithium has a narrow therapeutic range of 0.6 to 1.2 mEq/L. A level of 2.2 mEq/L indicates ' moderate toxicity. The nurse should notify the health care provider immediately, as severe toxicity can cause tonic-clonic seizures, coma, or death. Treatment typically involves administering IV fluids to dilute the concentration of the medication, holding the medication, and possible hemodialysis in severe cases.
The client may exhibit signs of toxicity such as confusion, slurred speech, and severe diarrhea. A mechanical soft diet will not treat the toxicity. The nurse would hold the next dose and prepare to draw lab work, including lithium and electrolyte levels, BUN and creatinine, and a CBC.
Question 21.
The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis?
(a) air embolism
(b) clotting of the graft site
(c) dialysis encephalopathy
(d) disequilibrium syndrome
Answer:
(a) air embolism
Rationale: This client is exhibiting signs of an air embolism, which is a complication of hemodialysis.The nurse should stop the dialysis immediately and turn the client on the left side in the Trendelenburg's position. The health care provider should be notified immediately. The nurse should administer oxygen and assess vital signs and pulse oximetry. Positioning the client in this manner helps to trap the air in the right side of the heart so it cannot travel to the lungs. Clotting at the graft site would be present when there is no thrill to palpate or a bruit to auscultate.
A clotted graft site would not produce this client's signs. Dialysis encephalopathy is caused by aluminum toxicity from dialysate water that contains aluminum. Signs include mental cloudiness, speech disturbances, bone pain, and seizures. Disequilibrium syndrome is characterized by nausea and vomiting, headache, hypertension, muscle cramps, and confusion.
Question 22.
The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in?
(a) in the semi-Fowler's position
(b) on the same side of the kidney to be biopsied
(c) on the side opposite of the kidney to be biopsied
(d) prone with a pillow under the shoulders and abdomen
Answer:
(d) prone with a pillow under the shoulders and abdomen
Rationale:
Clients having a renal mass removed should be placed in a prone position with a pillow under the shoulders and abdomen. Options 1, 2, and 3 are incorrect positions for this procedure.
Question 23.
The nurse is reviewing labs of a newly admitted client. Which lab result would prompt the nurse to contact the health care provider?
(a) ALT 33 units/L
(b) BNP 760 pg/mL
(c) WBC 10,450 mcL
(d) direct bilirubin 0.2 mg/dL
Answer:
(b) BNP 760 pg/mL
Rationale:
BNP, or B-type natriuretic peptide, is a hormone released by the heart in response to pressure changes within the heart. It is used to gauge the severity of congestive heart failure. A normal range in a client with heart failure is 0 to 100 pg/mL. A BNP of 760 pg/mL indicates severe heart failure. ALT (alanine aminotransferase) tests liver enzymes.
The normal range of ALT is 7 - 56 units per liter, so a value of 33 units/L is within normal limits. WBC (white blood cell) count normally ranges from 4,500 to 11,000 mcL, so a value of 10,450 is within normal limits. Direct bilirubin is a by-product of RBC breakdown. Normal lab values for direct bilirubin range from 0 to 0.3 mg/dL, so a value of 0.2 mg/dL falls within normal limits.
Question 24.
The nurse is caring for an adult client with a total bilirubin of (b)1 mg/dL. Which signs and symptoms would the nurse expect to find? Select all that apply.
(a) itchy skin
(b) nausea
(c) pale stools
(d) colorless urine
(e) none; this is a normal lab value
Answer:
(a) itchy skin
(b) nausea
(c) pale stools
Rationale:
This is an elevated total bilirubin level. Signs and symptoms include itchy skin, nausea, and pale stools. Dark urine, not colorless urine, would be present. Normal total bilirubin levels range from 0.3 to 1.9
Question 25.
The nurse is caring for a client with hypoparathyroidism. The nurse understands that this client is at risk for which problem?
(a) hypercalcemia
(b) hypermagnesemia
(c) decreased phosphorus levels
(d) low parathyroid hormone levels
Answer:
(d) low parathyroid hormone levels
Rationale:
Clients with hypoparathyroidism have low parathyroid hormone levels on blood tests. Hypocalcemia, not hypercalcemia, is also present. Magnesium levels are decreased, while phosphorus levels are increased.
Question 26.
The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.
(a) epistaxis
(b) petechiae
(c) vomiting blood
(d) elevated hematocrit
(e) increased platelet count
Answer:
(a) epistaxis
(b) petechiae
(c) vomiting blood
Rationale:
Clients with thrombocytopenia have decreased platelets. The nurse would expect to see signs of bleeding such as epistaxis, petechiae, and vomiting blood. Hematocrit and platelet count would both be decreased in this client.
Question 27.
The nurse is educating a client newly diagnosed with gout regarding dietary choices. The nurse understands that further teaching is needed if the client orders which foods for lunch?
(a) fruit cup with corn bread and tea
(b) tuna fish sandwich with green peas
(c) a peanut butter sandwich with 1 percent milk
(d) low-fat cheese and crackers with blueberries
Answer:
(b) tuna fish sandwich with green peas
Rationale: Tuna, along with sardines, scallops, and organ meats, is high in purine and should be avoided by clients with gout. Green peas are a medium-purine food and should be limited to a half cup per day. Low-purine foods include fruit and fruit juices, corn bread, pasta, bread, nuts, and peanut butter. Tea, 1 percent or skim milk, low-fat cheese, and low-fat ice cream are suitable diet choices on a low- purine diet.
Question 28.
A client is scheduled for a CT of the brain with and without IV contrast dye to evaluate a possible hemorrhage. Which finding in the client's history should the nurse report immediately
to the health care provider?
(a) allergy to shellfish
(b) history of schizophrenia
(c) allergy to cephalosporins
(d) presence of a pacemaker
Answer:
(a) allergy to shellfish
Rationale: Shellfish allergy is a possible contraindication to IV contrast medium. Depending on the severity of the allergy, IV diphenhydramine may be given. A history of schizophrenia and allergy to cephalosporins is not a contraindication to contrast dye. The presence of a pacemaker does not affect the use of contrast dye.
Question 29.
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT).
Following the procedure, the nurse should be watching for which serious complications?
Select all that apply.
(a) skin burns
(b) airway compromise
(c) cardiac dysrhythmias
(d) loss of bladder control
(e) neurological complications
Answer:
(b) airway compromise
(c) cardiac dysrhythmias
(e) neurological complications
Rationale:
Serious complications of electroconvulsive therapy (ECT) include airway compromise, cardiac dysrhythmias, and neurological complications. The nurse should monitor vital signs and assess for the return of the gag reflex. Telemetry can detect changes in heart rhythm. Neurological complications include numbness and tingling and memory loss. Orienting the client and performing neurological assessments are part of the recovery process. Skin burns are rare and mild side effects most commonly caused by improper lead placement. Loss of bladder control is not a serious complication. The client should be offered toileting before the procedure.
Question 30.
The nurse is reviewing arterial blood gases (ABGs) on a client. Which finding would prompt the nurse to notify the health care provider?
(a) pH 7.42
(b) pH 7.67
(c) hC03 24 mEq/L
(d) paC02 41 mmHg
(e) paC02 44 mmHg
Answer:
(b) pH 7.67
Rationale:
The normal pH is 7.35 - 7.45. A pH of 7.67 is highly alkalotic and should be reported immediately to the health care provider. The normal range for hCO3 is 22 - 26 mEq/L. The normal range for paCO2 is 35 - 45 mmHg. ABGs are used to assess how well the lungs move oxygen into the blood and remove carbon dioxide. They are used to guide ventilator settings in clients who require mechanical ventilation.
Question 31.
The nurse is preparing the client for a liver biopsy. Which statement by the client indicates a need for further instruction regarding the procedure?
(a) "I can resume strenuous activity in 2 to 3 days."
(b) "I will have to lay on my right side after the procedure."
(c) "I will have a small bandage instead of stitches afterward."
(d) "My right shoulder may begin to hurt as the anesthesia wears off."
(e) "I may have a small amount of pain or discomfort during the procedure."
Answer:
(a) "I can resume strenuous activity in 2 to 3 days."
Rationale:
Following a liver biopsy, the client should avoid lifting, straining, and coughing for 1 to 2 weeks. The client must lay on the right side following the procedure and may experience some pain or discomfort throughout. The client should expect some pain in the right shoulder as anesthesia wears off. Generally a small bandage is required to cover the incision.
Question 32.
The nurse is caring for a client receiving warfarin therapy for atrial fibrillation. Laboratory results show an INR of (c)9. The nurse would expect which order from the health care provider?
(a) an order to increase the warfarin dose
(b) an order to decrease the warfarin dose
(c) an order for protamine sulfate
(d) no new order; the INR is therapeutic
Answer:
(b) an order to decrease the warfarin dose
Rationale:
The therapeutic INR is generally 2.0 to 3.0, so the nurse should expect an order to decrease the warfarin dose. Increasing the warfarin dose increases the risk of bleeding. Protamine sulfate is the antidote for heparin, not warfarin. The client should be observed closely for signs of bleeding until the INR stabilizes in a therapeutic range.
Question 33.
The nurse is educating a client who has been ordered to wear a Holter monitor. Which statement by the client indicates a need for further education by the nurse?
(a) "I can wear the monitor while I shower."
(b) "I should keep the monitor on when I sleep."
(c) "I should avoid metal detectors and electric razors while wearing the monitor."
(d) "I should keep a log of any chest pain, shortness of breath, or skipped beats while wearing the monitor."
Answer:
(a) "I can wear the monitor while I shower."
Rationale:
The Holter monitor cannot be worn while swimming or bathing and should be kept dry. The monitor stays in place for the entire time monitoring is performed, including sleep. Metal detectors, electric razors, microwaves, and other electrical devices may interfere with the signal and should be avoided. Cell phones should be kept at least 6 inches away from the monitor. Clients should keep a log and note any chest pain, shortness of breath, or skipped heart beats while wearing the monitor.
Question 34.
The nurse is caring for a client with diabetes whose HgbAl C level is (f)9. The client asks the nurse what this means. Which response by the nurse is appropriate?
(a) "Your level is within target range and indicates good glycemic control."
(b) "Your level is too high, and you will need to increase your medications."
(c) "Your level is too low, and you will need to decrease your medications."
(d) "Your health care provider may want to place you on an insulin pump."
Answer:
(a) "Your level is within target range and indicates good glycemic control."
Rationale:
An A1C level below 7 is the target goal for most clients with diabetes, as it indicates good glycemic control. Given the A1C level of 6.9, there is no indication to increase or decrease medications. Since the client's A1C is within the goal, there is no indication that the client needs an insulin pump.
Question 35.
The nurse is caring for a client who just had an arteriovenous (AV) fistula placed for dialysis. The nurse is providing home care instructions to the client. Which statement by the client indicates a need for further teaching by the nurse?
(a) "I should avoid wearing a watch on my arm with the fistula."
(b) "It may take several weeks before the fistula is ready to use."
(c) "I should not have my blood pressure taken in my access arm."
(d) "I should wear tight sleeves to protect and support the fistula so I don't bend it."
Answer:
(d) "I should wear tight sleeves to protect and support the fistula so I don't bend it."
Rationale:
Clients with AV fistulas should avoid wearing tight sleeves or jewelry over the access area because restricting the blood flow may lead to clotting. A watch should be switched to the opposite arm. Fistulas take several weeks to mature to the point where they may be used. Blood pressures should not be taken in the arm with the fistula. The client should also not have needle sticks in the access arm.
Question 36.
The nurse is caring for a client who is undergoing a pharmacological stress test because she cannot use the treadmill. The nurse administers the prescribed dose of adenosine. Which physiological response indicates an adverse effect of the adenosine requiring intervention by the nurse? Select all that apply.
(a) nausea
(b) RR of 18
(c) HR of 97
(d) chest pain
(e) facial flushing
Answer:
(a) nausea
(d) chest pain
(e) facial flushing
Rationale:
Adverse effects of adenosine include nausea, chest pain, and facial flushing. The nurse should stop the infusion and monitor the client for abatement of symptoms. Adenosine has a half-life of 10 seconds, so symptoms should resolve shortly. A respiratory rate of 18 and heart rate of 97 are within normal limits and do not require any intervention.
Question 37.
The nurse is caring for a client who was admitted with an upper respiratory infection. The client's temperature is 10(b)4°F, and he is confused. In the last 2 hours, systolic blood pressure has dropped from 138 to 90. The nurse should perform which intervention? Select all that apply.
(a) obtain blood cultures
(b) place the client on NPO status
(c) administer supplemental oxygen
(d) administer antipyretics as ordered
(e) encourage rest and limit physical activity
(f) provide a warming blanket to alleviate chills
Answer:
(a) obtain blood cultures
(c) administer supplemental oxygen
(d) administer antipyretics as ordered
(e) encourage rest and limit physical activity
Rationale:
Based on the confusion and drop in systolic blood pressure, the client may be becoming septic. The nurse should obtain blood cultures to determine if bacterial infection is triggering the response; this will also indicate which antibiotics would be effective. Fever can decrease oxygenation, so the client should be placed on oxygen. Antipyretics should be administered, and the nurse should follow up and recheck the temperature in 30 minutes or so to see if it is decreasing.
The client should rest and avoid physical activity. There is no need to make the client NPO; fluids help with hydration and should be encouraged if the client can drink. Although the client may want a blanket if experiencing chills, the room temperature should be decreased and excess blankets removed.
Question 38.
Mix and Match: Match the laboratory test to the abnormal value.
|
Laboratory Test |
Abnormal Value |
|
calcium |
8.1 mg/L |
|
PH |
7.56 |
|
specific gravity |
1.000 |
|
potassium |
5.8 |
|
LDL |
160 mg/dL |
|
HDL |
34 mg/dL |
Answer:
|
Laboratory Test |
Normal Value |
|
calcium |
8.5 - 10.9 mg/L (serum) |
|
PH |
7.35 - 7.45 (arterial blood gases) |
|
specific gravity |
1.010 - 1.030 (urine) |
|
potassium |
3.5 - 5.1 |
|
LDL |
Less than 100 mg/dL (serum) |
|
HDL |
40 - 59 mg/dL (serum) |
Question 39.
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
(a) place the client in restraints or mitts
(b) tell the family that they need to stay with the client
(c) replace the IV and wrap it in gauze to hide it from view
(d) tell the client that if she pulls another IV out, she will have to have a PICC line placed
Answer:
(c) replace the IV and wrap it in gauze to hide it from view
Rationale:
Many clients with dementia pull out an IV because they see it and know that they don't normally have one. Placing the IV in an inconspicuous place, such as where it can be covered by the gown or wrapped up in gauze, prevents the client from pulling it out, because he cannot see it. Restraints should not be the first-line intervention for this client, as this may increase confusion and agitation. If the family can stay with the client, they can help watch, but many clients do not have family close by that can stay with them around the clock. Threatening the client with a more invasive procedure should never be used as a means of obtaining cooperation.
Question 40.
A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document?
(a) maculopapular rash
(b) heat rash
(c) vesicular rash
(d) pustular rash
Answer:
(c) vesicular rash
Rationale:
Vesicular rashes contain small raised, sacs filled with clear liquid. A maculopapular rash is characterized by a flat, red area on the skin covered with small confluent bumps. A heat rash appears as tiny red pimples, bumps, or spots usually on the back of the neck or lower back. Pustular rash presents with pustules smaller than 5-10 mm filled with pus.
Question 41.
A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention?
(a) wash the hair for three continuous days with dandruff shampoo
(b) isolate all clothing of the child for one week
(c) treat with an approved pediculicide agent according to directions
(d) shave the child's head, then cleanse with herbal shampoo
Answer:
(c) treat with an approved pediculicide agent according to directions
Rationale:
Treating hair lice most commonly requires application of an over-the-counter pediculicide (medication that kills lice). Leave on the hair according to label instructions. If the child has long hair, a second bottle may be necessary. Washing the hair with dandruff shampoo is ineffective. For clothing and items that cannot be washed in hot water/hot heat drying, sealing them in a plastic bag for two weeks is recommended. Shaving the child's head and cleansing with herbal shampoo is ineffective.
Question 42.
A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply.
(a) offer a communication board
(b) ask simple yes/no questions
(c) ask open-ended questions
(d) offer an electrolarynx
Answer:
(b) ask simple yes/no questions
Rationale:
Communication boards are highly effective in allowing clients to express their needs. Similarly, yes/no questions allow ease in communicating needs with minimal frustration. Open- ended questions require oral communication the client with an endotracheal tube cannot perform. An electrolarynx, a battery-powered handheld device that transmits sound when pressed against the oropharyngeal cavity, is used for clients with a tracheostomy.
Question 43.
A nurse is teaching a client with left-sided hemiparesis to walk with a cane. The nurse should include which points about safe cane use when teaching the client? Select all that apply.
(a) hold the cane in the right hand
(b) hold the cane in the left hand
(c) move the cane and step forward with the right leg
(d) move the cane and step forward with the left leg
Answer:
(a) hold the cane in the right hand
(d) move the cane and step forward with the left leg
Rationale:
The client should hold the cane in the hand opposite the weaker leg, the right hand. The client should move the cane and step forward with his weaker leg, left, at the same time.
Question 44.
The nurse is assessing a client with Addison's disease. The nurse expects to note which of the following?
(a) craving of salty foods
(b) weight gain
(c) craving of sweet foods
(d) hyperactivity
Answer:
(a) craving of salty foods
Rationale:
The impaired ability of the adrenal gland to produce the hormone aldosterone (a mineralocorticoid), which helps the kidney retain sodium, results in a craving for salty foods. Weight loss is associated with the disease. Loss of appetite, rather than craving for sweet foods, is consistent with Addison's disease. Fatigue and muscle weakness are typically seen with Addison's disease.
Question 45.
An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client?
(a) "Tell me when you feel me touch your arm."
(b) "Tell me when you stop hearing the tuning fork sound."
(c) "Do you have problems with balance?"
(d) "How much is two plus four plus seven?"
Answer:
(d) "How much is two plus four plus seven?"
Rationale:
Asking the client to add a simple series of numbers tests problem solving, a function of the frontal lobe. Tactile sensation is a parietal lobe function. Hearing function is a temporal lobe function. Balance is a function of the cerebrum.
Question 46.
A client is admitted to the ED after complaining of acute chest pain radiating down the left arm. The client is diaphoretic and anxious, and has difficulty breathing. Which laboratory studies would the nurse anticipate?
(a) blood urea nitrogen (BUN)
(b) white blood cell count
(c) LDH
(d) myoglobin
Answer:
(d) myoglobin
Rationale:
Myoglobin, a small hemeprotein, becomes abnormal within 1 - 2 hours of myocardial infarction (Ml). BUN and white blood cell levels do not provide relevant information when an Ml is suspected. LDH, lactate dehydrogenase, will begin to rise 2-5 days after an Ml.
Question 47.
A nurse is monitoring a client's intracranial pressure (ICP) after a motor vehicle accident. Upon checking the ICP, the nurse knows to contact the physician. What reading would warrant this action?
(a) 8 mm Hg
(b) 14 mm Hg
(c) 18 mm Hg
(d) 22 mm Hg
Answer:
(d) 22 mm Hg
Rationale:
In a healthy adult the ICP is 5 - 15 mm Hg. Any pressure greater than 20 mm Hg after a head injury is abnormal.
Question 48.
A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply.
(a) provide the client with a call-light device
(b) keep the bed in the lowest position
(c) use a beveled floor mat at bedside
(d) implement a bed alarm
Answer:
(b) keep the bed in the lowest position
(c) use a beveled floor mat at bedside
(d) implement a bed alarm
Rationale:
Keeping the bed in the lowest position reduces the impact if the client falls from the bed. Special flooring provides a cushioned surface that reduces impact. A bed alarm will notify staff if the client moves from the bed. Providing a call-light device to a client with Parkinson's is ineffective as the client's ability to use the device is impaired because of fine motor movement limitation.
Question 49.
While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply.
(a) instruction on high fiber diet the day before the procedure
(b) instruction that a sedative will be administered before the procedure
(c) instruction not to eat or drink 6-12 hours before the procedure
(d) instruction not to eat or drink 18 hours before the procedure
Answer:
(b) instruction that a sedative will be administered before the procedure
(c) instruction not to eat or drink 6-12 hours before the procedure
Rationale:
Before the procedure a sedative will be administered. The typical pre-procedure diet is low fiber or clear liquids only for one to three days prior to the procedure. Clients should not eat or drink 6 - 12 hours pre-procedure.
Question 50.
A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority?
(a) sterile wound management
(b) elevation of residual limb
(c) performing prescribed exercises
(d) reporting occurrence of phantom limb pain immediately
Answer:
(c) performing prescribed exercises
Rationale:
The nurse should advise the client to exercise as instructed to prevent contracture formation. Aseptic dressing wound management is acceptable. Elevation of the residual limb should be avoided to prevent contracture formation. As phantom limb pain is common, reporting on an imminent basis is unnecessary.
Question 51.
A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply.
(a) excessive sweating
(b) constipation
(c) inability to tolerate cold
(d) leg cramps
Answer:
(a) excessive sweating
(d) leg cramps
Rationale:
Excessive sweating and leg cramps are side effects of thyroid replacement therapy. Diarrhea rather than constipation is a side effect of thyroid replacement therapy. Inability to tolerate heat rather than cold is a side effect as well.
Question 52.
A client is having a tonic-clonic seizure. Which of the following should the nurse do first?
(a) call for assistance
(b) restrain the client
(c) turn the client on her side
(d) provide a safe environment
Answer:
(d) provide a safe environment
Rationale:
As safety is the top priority during seizure activity, the nurse should remove any objects in the immediate area that may cause the client harm. Calling for assistance is not the first course of action. Restraining a client during a seizure is contraindicated. Turning the client on her side is important yet it is a secondary action.
Question 53.
The nurse is preparing to discharge a client with an ileal conduit done for treatment of bladder cancer. Which statement by the client indicates the need for further instruction?
(a) "I look forward to returning to my local health club to swim."
(b) "The local ostomy support group meets on Wednesday morning at 10 a.m."
(c) "My stoma should be cleaned daily with soap and water."
(d) "During the day I will wear a leg bag to collect my urine."
Answer:
(a) "I look forward to returning to my local health club to swim."
Rationale:
During the initial postoperative period after an ileal conduit, the client should not swim due to the risk of infection. Attendance at an ostomy support group will help the client deal with altered body image. Cleaning the stoma with soap and water will help reduce chance of infection. Wearing a leg bag during the day to collect urine allows the client to return to a normal lifestyle. At night, a larger urine collection bag will be needed.
Question 54.
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing?
Select all that apply.
(a) replace electric razor with a straight razor
(b) encourage frequent periods of rest
(c) instruct on a potassium-restricted diet
(d) monitor the client's mental status
Answer:
(b) encourage frequent periods of rest
(d) monitor the client's mental status
Rationale:
Due to diffuse destruction of hepatic cells with cirrhosis of the liver, the client will experience fatigue and need frequent rest periods throughout the day. An inability of the liver to filter toxins can lead to hepatic encephalopathy making assessment of the client's mental status imperative. Due to impaired clotting function, clients need safety measures implemented such as replacing a straight shaving razor with an electric one. Sodium rather than potassium should be restricted with cirrhosis of the liver.