Fundamentals Exam 2 NCLEX Qs

The nurse takes a medication to a patient, and the patient refuses to take it and tells the nurse to take it away. Which action would the nurse take? 1.Ask the patient's reason for refusal. 2.Explain that he or she must take the medication. 3.Take the medication away and chart the patient's refusal. 4.Tell the patient that her physician knows what is best for him or her.

1.Ask the patient's reason for refusal. When patients refuse a medication, first ask why they are refusing it. The nurse would not tell patients they must take the medication. Nurses cannot document a reason unless they know the reason. The nurse would not tell the patient the physician knows what is best for him or her because the patient has the right to refuse.

When deciding on what time of day to give medications, the nurse pays closest attention to the client's habits regarding: 1.Eating 2.Sleeping 3.Elimination 4.Activity

1.Eating Eating is the most important of these because food in the stomach must be a consideration.

Absorption, distribution, and excretion may be increased by which of the following diseases? 1.Hyperthyroidism 2.Renal insufficiency 3.Liver disease Hypothyroidism

1.Hyperthyroidism Diseases that speed up metabolism, such as hyperthyroidism, will increase absorption, distribution, and elimination. Diseases that decrease metabolism, such as hypothyroidism, renal insufficiency, and liver disease, will slow these metabolic processes.

A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? 1.Kinking of the ventilator tubing 2.A disconnected ventilator tube 3.An endotracheal cuff leak 4.A change in the oxygen concentration without resetting the oxygen level alarm

1.Kinking of the ventilator tubing

During an evaluation of a patient with elastic bandages, the nurse observes signs of impaired circulation in the surrounding area. Which action by the nurse would be priority? 1.Release the bandage. 2.Palpate the extremity. 3.Assess the pulse. 4.Reapply the bandage with less pressure.

1.Release the bandage. The nurse's priority is to release the bandage when impaired circulation is observed during evaluation. Once this is done, the nurse can then perform the lower-priority actions of palpating the extremity, assessing the pulse, and reapplying the bandage with less pressure.

Which clinical manifestation occurs with right-sided heart failure? Select all that apply. One, some, or all responses may be correct. 1.Weight gain 2.Distended neck veins 3.Pedal edema 4.Heart murmur 5.Lung crackles

1.Weight gain 2.Distended neck veins 3.Pedal edema Weight gain, distended neck veins, and pedal edema indicate right-sided heart failure. The blood starts pooling in the systemic circulation, resulting in weight gain, distended neck veins, and pedal edema. A heart murmur occurs with impaired valvular function, not right-sided heart failure. Lung crackles occurs with left-sided heart failure, not right-sided heart failure. •To differentiate left-sided heart failure from right-sided heart failure clinical manifestations/signs & symptoms, remember this: •Left-sided heart failure produces Lung manifestations/signs & symptoms (crackles, hypoxia, shortness of breath, cough, paroxysmal nocturnal dyspnea) whereas •Right-sided heart failure is the Rest of the body (weight gain, pedal edema, distend

Which nursing action is appropriate in reducing the risk associated with increased intracranial pressure (ICP) during suctioning of a patient with a head injury? Select all that apply. One, some, or all responses may be correct. 1.Administering oxygen at a rate of 3 L/min 2. Correct Hyperventilating the patient prior to suctioning 3. Suctioning the mouth with a separate oral suction device 4. Using normal saline instillation into the airway before suctioning 5. Correct Limiting the introduction of the catheter to 2 times with each suctioning procedure

2. Correct Hyperventilating the patient prior to suctioning 5. Correct Limiting the introduction of the catheter to 2 times with each suctioning procedure This risk is reduced by hyperventilating the patient prior to suctioning and limiting the introduction of the catheter to 2 times with each suctioning procedure. The nurse is cautious while suctioning patients with head injuries because suctioning elevates the ICP. To hyperoxygenate a patient, 100% oxygen is used, not 3 L/min. Although the mouth can be suctioned with a separate suctioning device, it is avoided in a patient with a head injury because suctioning itself can increase ICP. Normal saline instillation in conjunction with suctioning is not recommended anymore; it is harmful and could cause more damage in a patient with a head injury.

A patient experiences impaired oxygenation due to postoperative atelectasis. When planning care for the patient, which goal does the nurse prioritize to resolve the condition? 1.Reduce oxygen to 2 L/nasal cannula. 2. Use incentive spirometer hourly as instructed. 3. Decrease respiratory rate to 18 breaths/min. 4. Perform nebulizer treatments independently.

2. Use incentive spirometer hourly as instructed. Atelectasis occurs when lungs are not expanding to their full capacity, causing alveolar collapse. The way to improve oxygenation with atelectasis is deep breathing and incentive spirometry. Thereforean appropriate goal is to use the incentive spirometer every hour as instructed by the nurse. Reducing oxygen and decreasing the respiratory rate shows improvement, but not that a goal is met. Performing nebulizer treatments independently would be a goal toward self-management.

Which statement is accurate regarding the steps involved in administering medications by inhalation? 1.The alveolar-capillary network absorbs medications slowly. 2.Breath-actuated metered-dose inhalers (BAIs) do not use a spacer. 3.Ten to 20 pounds of pressure is applied to the canister to administer the medication. 4.A spacer is 8 to 10 inches in length and allows the particles of medication to slow down.

2.Breath-actuated metered-dose inhalers (BAIs) do not use a spacer. BAIs do not use a spacer. BAIs release medication when a patient raises a lever and inhales. The alveolar-capillary network absorbs medications rapidly. Five to 10 pounds of pressure is applied to the canister to administer the medication. A spacer is a tube that is 10.16 to 20.32 cm (4 to 8 inches) in length that attaches to a pressurized metered-dose inhaler (MDI) and allows the particles of medication to slow down and break into smaller pieces.

Which abnormality is caused by chronic hypoxemia? 1.Edema 2.Clubbing 3.Cyanosis 4.Splinter hemorrhages

2.Clubbing Clubbing in the fingertips is associated with chronic hypoxemia. Edema is associated with right-sided heart failure, not hypoxemia. Neck vein distention is caused by right-sided heart failure, not chronic hypoxemia. Splinter hemorrhages are caused by infective endocarditis, not chronic hypoxemia.

Which statement about dry powder inhalers requires correction? 1.The medication inside a dry powder inhaler can clump if exposed to humid climate. 2.Few patients cannot inspire fast enough to administer the entire dose of the medication. 3.All dry powder inhalers require patients to load a single dose of medication into the inhaler with each use. 4.A dry powder inhaler is activated with the patient's breath, so there is no need to coordinate puffs with inhalation.

3.All dry powder inhalers require patients to load a single dose of medication into the inhaler with each use. Some dry powder inhalers are unit dosed. These inhalers require patients to load a single dose of medication into the inhaler with each use. Other dry powder inhalers hold enough medication for 1 month. The medication inside a dry powder inhaler can clump if the patient is in a humid climate because dry powders generally clump when exposed to humidity. Some patients cannot inspire fast enough to administer the entire dose of the medication. Dry powder inhalers require less manual dexterity. Because the device is activated with the patient's breath, there is no need to coordinate puffs with inhalation.

A patient has difficulty swallowing a capsule. Which action would the nurse take? 1.Split the capsule in half. 2.Use an alternate medicine. 3.Notify the health care provider. 4.Encourage the patient to take the capsule whenever he or she wants.

3.Notify the health care provider. While administering a medication, if a patient has difficulty swallowing a medication, the nurse should notify the health care provider. Capsules should not be split in half. The health care provider, not the nurse, can prescribe an alternate medicine. Encouraging the patient to take the capsule whenever he or she wants is not a correct nursing intervention.

How can the nurse administer medication to a patient with unilateral weakness without causing aspiration? 1.Provide the medication as a solution. 2.Place the medication in the weaker side of the mouth. 3.Place the medication in the stronger side of the mouth. 4.Crush the medication before administration.

3.Place the medication in the stronger side of the mouth. The patient with unilateral weakness may have an increased risk of aspiration because of impaired swallowing. To prevent aspiration, the medication should be placed in the stronger side of the mouth. This action improves swallowing of the medication. Providing medication as a solution increases the risk of aspiration. Placing the medication in the weaker side of the mouth may lead to inappropriate swallowing. Grinding the medication before administration does not reduce the incidence of aspiration.

The patient has a prescription for 2 tablespoons of magnesium hydroxide. How much medication does the nurse administer? 1.2 mL 2.5 mL 3.16 mL 4.30 mL

4. 30mL 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

The nurse accidently gives a patient a medication at the wrong time. Which action would the nurse take first? 1. Complete an occurrence report. 2. Notify the health care provider. 3. Inform the charge nurse of the error. 4. Assess the patient for adverse effects.

4. Assess the patient for adverse effects. Patient safety and assessing the patient are priorities when a medication error occurs. The first priority of the nurse is to assess and examine the patient's condition, and notify the health care provider of the incident as soon as possible. Once the patient is stable, report the incident to the appropriate person in the agency (e.g., manager or supervisor). The nurse is responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs.

Which statement made by the new nurse about suctioning a patient with an endotracheal tube indicates the charge nurse needs to intervene? 1."I'll use a sterile technique to suction the patient." 2."I'll apply suction while rotating and withdrawing the suction catheter." 3."I'll suction the mouth after I suction the endotracheal tube." 4."I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

4."I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." The charge nurse would intervene when the new nurse says, "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Saline instillation has been found to cause harm, is not recommended when suctioning, and does not increase the amount of secretions removed. The charge nurse would not need to intervene with the other statements because they are correct. The nurse would use a sterile technique. The nurse would apply suction while rotating and withdrawing the suction catheter, and the nurse would suction the mouth after suctioning the endotracheal tube.

After a surgical procedure, the patient experiences thrombocytopenia. For which condition would this postsurgical patient be at risk? 1.Infection 2.Dehiscence 3.Evisceration 4.Hemorrhage

4.Hemorrhage Hemorrhage or bleeding from the wound site normally continues for the patients with abnormally low platelets, such as thrombocytopenia. Wound infection occurs when microorganisms invade wound tissue. Dehiscence is the partial or total separation of wound layers, which occurs when an incision fails to heal properly. Evisceration occurs with total separation of the wound layers and requires surgical repair.

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? 1.Nausea or vomiting 2.Abdominal pain or diarrhea 3.Hallucinations or tinnitus 4.Lightheadedness or paresthesia

4.Lightheadedness or paresthesia •The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). •Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. •Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.