Question 1

Which finding on the admission assessment would make the nurse question the order for a cerebral angiogram for the client?

Accepted Answer

A cerebral angiogram often involves the use of iodine-based contrast dye, which can cause allergic reactions in individuals with a shellfish allergy. The nurse should question the order due to the client's history of hives when consuming shrimp or clams, indicating a potential allergy to the contrast dye.

Question 2

A 37-year-old woman has an internal radioactive implant placed for the treatment of uterine cancer. Select the action the nurse should take first when she finds the implant in the bed linens during routine care.

Accepted Answer

The first action the nurse should take is to place the implant in a lead-lined container with a pair of long-handled forceps to minimize radiation exposure. This is the safest way to handle the situation until further assistance can be obtained.

Question 3

In reviewing the chart of a 15-year-old client who suffered a head trauma in a sports accident, the nurse notes a serum potassium of 2.8 mEq/L and a serum sodium of 122 mEq/L. What addition to the nursing care plan would be most appropriate for the nurse to make based on this information?

Accepted Answer

The low serum potassium and sodium levels may indicate electrolyte imbalances, which can affect fluid balance and require close monitoring of intake and output to ensure adequate hydration and electrolyte balance. Option B is not relevant to this specific issue. Option C may be appropriate for other reasons but is not directly related to the electrolyte imbalances. Option D is not relevant to this issue.

Question 4

Choose the action by the nurse that takes highest priority in the treatment of a child with sickle cell anemia.

Accepted Answer

Maintaining hydration is crucial in the treatment of sickle cell anemia. Dehydration can trigger sickling of red blood cells and cause vaso-occlusive episodes, which can result in severe pain and tissue damage. Drinking plenty of water helps to prevent dehydration and promote blood flow, reducing the risk of painful crises. Range of motion exercises and reverse isolation may be helpful in some cases, but maintaining hydration takes highest priority. While analgesics can be used to manage pain, they should not be the only method of treatment.

Question 5

After a client is connected to a heart monitor in the emergency room, the nurse notes an elevated ST segment on the ECG strip. What nursing action would have the highest priority for this client?

Accepted Answer

An elevated ST segment on an ECG strip may indicate myocardial ischemia or infarction, which can lead to severe cardiac complications. Therefore, the nurse should assess the client's vital signs and degree and location of any chest pain as the highest priority. This information can help determine the severity of the condition and guide further interventions. Administering nitroglycerine or placing the client in the prone position should only be done after assessing the client's condition and with physician orders. Notifying the physician is important, but it should not be the first action taken without first assessing the client.

Question 6

Identify the additional assessment the nurse should make when the serum uric acid level of a 64-year-old man is 12.8 mg/dL.

Accepted Answer

High serum uric acid levels can indicate gout, a disorder characterized by joint inflammation, tenderness, and swelling. Therefore, the nurse should assess the patient's joints for tenderness and swelling. options A, B, and C are not directly related to the patient's high serum uric acid levels.

Question 7

After reviewing the lab results for the clients to which the nurse is assigned, select the client the nurse should assess first.

Accepted Answer

The elevated level of cTnT, a cardiac enzyme, indicates possible cardiac injury or myocardial infarction. This client requires immediate assessment and intervention. CPKMB and LDH levels can also indicate cardiac injury, but cTnT is the most specific marker. The triglyceride level is high but does not require immediate assessment and intervention.

Question 8

Identify the action the nurse should take first when the low tidal volume alarm on a positive pressure, volume-cycled ventilator begins and continues to sound.

Accepted Answer

Checking for separation of the ventilator tube from the endotracheal tube should be the first action taken because if separation has occurred, the client may not be receiving adequate ventilation and oxygenation. This is an urgent issue that requires immediate attention. Checking for water buildup, disconnecting the oxygen supply, or encouraging coughing may also be appropriate actions, but they should be done after ensuring that the client is properly connected to the ventilator.

Question 9

Identify the action by the nurse that would best promote a positive therapeutic community milieu when several clients in the psychiatric inpatient unit ask the unit manager if she could extend the visiting hours until 9 p.m.

Accepted Answer

Encouraging clients to bring their concerns to the next community meeting promotes a positive therapeutic community milieu by fostering open communication, collective problem-solving, and empowerment among the clients. This approach supports the principles of therapeutic communities by involving clients in decision-making processes and encouraging active participation in the community.

Question 10

Choose the action the nurse should take to elicit the oculocephalic response in a motor vehicle accident victim who is unconscious.

Accepted Answer

The oculocephalic reflex, also known as the doll's eye reflex, is tested by holding the patient's eyelids open and quickly turning the head from side to side. This action checks for the presence of brainstem function by observing the eyes' movement in the opposite direction of the head turn. Options A, C, and D describe other neurological tests (corneal reflex, caloric reflex test, and pupillary light reflex, respectively), not the oculocephalic reflex.

Question 11

During the 0700 beginning of the shift assessment, the nurse finds a client who was diagnosed with type I diabetes mellitus to be difficult to arouse. Per unit protocol, arterial blood gases and a blood glucose are performed. The results show pH 7.01, PO₂ 92, PCO₂ 36, HCO₃ 9, blood glucose 873. What action should the nurse take first?

Accepted Answer

The client's acidosis and high blood glucose levels indicate a medical emergency known as diabetic ketoacidosis (DKA). The first priority is to establish an IV line with 0.5% normal saline to prevent dehydration and administer sodium bicarbonate to correct the acidosis. The physician and house supervisor should also be notified immediately, but this should occur after starting IV fluids and administering sodium bicarbonate. Administering NPH insulin or attempting to determine the cause of the high blood glucose level can wait until the client's immediate medical needs are addressed.

Question 12

Identify the nursing action that is most appropriate for a client who is diagnosed with injury to cranial nerves IX and X after a blow to the head.

Accepted Answer

Cranial nerves IX and X play a major role in swallowing and speaking, therefore it is most appropriate to maintain the client in an NPO (nothing by mouth) status until a swallowing evaluation can be performed by a speech therapist to prevent aspiration. The other options are not directly related to the injury of cranial nerves IX and X.

Question 13

Which postbronchoscopy assessment observed by the nurse in a 54-year-old woman would require immediate intervention?

Accepted Answer

The presence of stridor in the upper airway is a serious complication that could indicate airway obstruction and require immediate intervention to prevent respiratory distress or failure. Coughing up blood-tinged mucus is a common post-bronchoscopy symptom and can be managed with observation and suctioning as needed. A negative gag reflex after 15 minutes is not of immediate concern, but the nurse should continue to monitor the patient for possible complications. Difficulty arousing with initial disorientation may also be expected after moderate sedation and should be closely monitored, but does not require immediate intervention unless the patient is unresponsive or in distress.

Question 14

Select the instruction given by the nurse to a group of senior citizens attending a class on aging at a senior center that best addresses the normal age-related changes in the skin.

Accepted Answer

Option C is the best choice as it addresses the normal age-related change in the skin where the healing process slows down. This is important information for seniors to know as they may need to take extra care of even minor cuts to prevent infections or complications. Option A is incorrect as emollients are actually beneficial for older skin, which tends to become drier and less elastic. Option B is unrelated to age-related changes in the skin, and option D is about changes in fingernail/toenail growth, not skin.

Question 15

Select the nursing action that takes highest priority in providing care for a client diagnosed with an organic brain syndrome.

Accepted Answer

Providing a safe environment to prevent injury takes highest priority when caring for a client diagnosed with an organic brain syndrome because they may have impaired judgment, altered mental status, or confusion that can increase their risk for falls or accidents. It is essential to create a safe environment by reducing clutter, maintaining proper lighting, and ensuring that the client is supervised.

Question 16

While reviewing the laboratory results for a client, the RN notes that pulmonary function test values are as follows: residual volume: 1800 mL; vital capacity: 2300 mL; tidal volume: 275 mL. Identify the nursing action included in the care plan developed by the LPN that the RN would change.

Accepted Answer

Based on the pulmonary function test values provided, it appears that the client may be experiencing pulmonary obstruction. Increasing the oxygen flow rate may not be the most appropriate nursing action to address the client's shortness of breath in this case. The RN would likely recommend consulting with the healthcare provider to explore other interventions such as bronchodilators or corticosteroids to address the underlying pulmonary condition.

Question 17

Select the teaching point the community health nurse should emphasize as a clue to possible attempted suicide when conducting a parenting class about suicidal ideation in school-aged children.

Accepted Answer

Giving away favorite possessions can be a sign that an individual is contemplating suicide. It is important for parents and caregivers to recognize this behavior and seek help for the child. Poor grades, smoking, and aggressive behavior may be signs of other issues, but they are not specific clues to possible suicide attempts.

Question 18

A 78-year-old client who experiences angina after even minimal activity is treated with medications. Identify the medication mode of action that the nurse would give to best decrease myocardial oxygen consumption and reduce chest pain.

Accepted Answer

Reducing afterload decreases the resistance the heart has to work against to eject blood, thereby reducing myocardial oxygen consumption and alleviating chest pain.

Question 19

Identify the action the nurse takes to best prevent contractures in a client with second- and third-degree burns of the legs.

Accepted Answer

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Question 20

Identify the statement made by a client that would indicate to the nurse that additional teaching was required for a client who was scheduled for a lumbar puncture.

Accepted Answer

The statement "I can get up and go to the bathroom within 1 hour after the procedure" indicates a lack of understanding about the need for bed rest and decreased physical activity after a lumbar puncture. Therefore, additional teaching is required. The other statements are either correct or not relevant to the procedure itself.

Quiz 11: Nclex: What You Need to Know