FINAL: NCLEX Questions

A student nurse is assessing a patient with Parkinson's disease. The patient has slow movements that affect their facial expressions, swallowing, and ability to coordinate movements. The student nurse will document the patient's symptoms as: A. Pill-rolling B. Akinesia C. Dysphagia D. Bradykinesia E. Apraxia

D. Bradykinesia

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statements reflects a need for further teaching? 1. "I can sit down to put my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

4. The client with Parkinson's disease should be instructed regarding the safety measures in the home. The client should use her or his walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent failing. The client should exercise every day in the morning when energy levels are the highest. The client should have all loose rugs in the home removed to prevent failing.

Which ED patient is most likely to be diagnosed with HHS? a) A 65yo man with BG of 720 mg/dL and pH of 7.40 who felt okay yesterday but has poor skin turgor and dry oral mucosa. He has recently been prescribed prednisone for ulcerative colitis and hasn't been able to check his BG in a few days because he lost his glucose meter. b) A 35 yo woman with a BG of 150 mg/dL, pH of 7.37 and ketones 3+ in her urine. She is awaiting an ortho consult for a possible metatarsal stress fracture acquired trying to top her personal best trail running at Percy Warner. She has been harassing you about the lack of carb-free cafeteria options if she is going to be here much longer, because she spilled half of her post workout avocado smoothie trying to drive herself here. c) A 21 yo man with a BG of 350mg/dL and pH of 7.29. He recently went to Cancun for spring break 4 weeks after being diagnosed with DM Type 1. He swears he didn't contract the Rona, but he did wind up with a nasty Giardia infection after swallowing a mouthful of water swimming in a cenote. He also only brought 4 days' worth of insulin for a week long trip so he had been "rationing it" and supplementing with shots of tequila since they told him booze would lower his blood sugar. d) A 45 yo woman newly diagnosed with type 2 DM whose BMI is 29 who has been working out with a trainer 5 days a week since her diagnosis. She usually eats before and after each training session but forgot today and passed out doing burpees.

A) 65yo with UTI. Rationale: Glucocorticoids increase risk of hyperglycemia, he wasn't checking his BG regularly. Poor turgor and dry music membr anes are s/s of both DKA and HHS.BG over 700, normal pH B) This lady needs a Snickers, she's in ketosis. D) Girl is TRYING, but this lady is hypoglycemic.

What is a common symptom of Respiratory Alkalosis? Select all that apply A) Hyperventilation B) Hypoventilation C) Confusion D) Paralysis

A) Hyperventilation C) Confusion Respiratory Alkalosis occurs when Hyperventilation occurs. When breathing out too fast, PaCo2 is lost in that cycle, causing Respiratory Alkalosis. Hypoventilation causes Respiratory acidosis from inadequate respirations to breathe out enough PaCO2. Confusion is a common symptom of respiratory Alkalosis from the low PaCO2. Paralysis is not a symptom.

A 60yo female patient presents to the ED with a BG of 750 mg/dL and a K+ of 3.6 mEq/L. She is given an IV and started on 0.45% NS and regular insulin. What action do you anticipate when the patient's glucose reaches 250 mg/dL? a) Administer IV fluids containing 5% dextrose. b) Assess cardiac monitoring for peaked T waves. c) Administer Kayexalate (sodium polystyrene sulfate). d) Discontinue the IV.

A) IV fluids w/ dextrose. When blood glucose levels fall to approximately 250 mg/dL, IV fluids containing dextrose are administered to prevent hypoglycemia. Hyperkalemia causes peaked T waves which he doesn't have. Kayexalate is used to treat hyperkalemia which he doesn't have; in fact, we're more worried about hypokalemia after insulin administration. Don't discontinue the IV, you still need it. See above

Which of the following options would be most appropriate for the patient with a PH 7.5, PaCO2 26mm Hg, O2 sat 96%, HCO3 24mEq/L, and PaO2 94 mm Hg? A) Instruct patient to breathe into a paper bag B) Administer a prescribed decongestant C) Offer the client fluids D) Administer prescribed supplement oxygen

A) Instruct patient to breathe into a paper bag The results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag.

A nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder? a. Metabolic acidosis b. Metabolic Alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A) Metabolic Acidosis Prolonged diarrhea can cause Metabolic Acidosis by expelling too much bicarbonate in feces. It cannot cause any of the other listed imbalances.

A patient states they have been vomiting x 4 days. The patient is irritable, weak, and reporting muscle cramping and weakness. On assessment, the patient is experiencing bradypnea with respiratory rate of 10. Patient's ABG: pH 7.52, PaCO2 48, HCO3 36. Which acid base condition is this patient presenting? a) Metabolic alkalosis, partially compensated b) Metabolic alkalosis, fully compensated c) Metabolic acidosis, partially compensated d) Metabolic acidosis, no compensation

A) Metabolic Alkalosis Partially Compensated The HCO3 value is higher than 26, meaning it is alkalotic and making this a metabolic imbalance (because bicarb is secreted by liver), showing that this imbalance is compensated. The pH is alkalotic, because it is above 7.45. When the pH is out of normal range, this means the imbalance is partially compensated. The patient also has signs of bradypnea with a RR of 10, which could cause the patient to retain more CO2, causing the levels to be high (48).

A patient is being treated in the ED for severe third degree burns. What signs and symptoms would make the nurse suspect the patient has third spacing? (Select all that apply) A. Tachycardia B. Hypertension C. Edema D. Increased Urine Output E. Weak pulse

A,C,E Third spacing can occur after trauma or burns. Signs and symptoms include: Ascites, Edema, Tachycardia, Hypotension, Weak Pulse, Decreased Urine Output

You are a Nurse in the Cardiac step-down unit. Your patient's ECG is showing signs of hypokalemia. What alterations to the ECG will you, the nurse, see? (Select all that apply) a. Peaked P waves b. Normal QRS segment c. Normal T wave d. Presence of a U wave e. Normal ST segment

A,D The ECG of someone with hypokalemia will have peaked P waves, QRS segment that is longer, flattened T wave, presence of U wave, and a depressed ST segment. Not having enough potassium affects the way your muscles work. It can also cause dysrhythmias that you would potentially hear when assessing or see on an ECG.

The daughter of a patient with Alzheimer's disease states "So you guys are going to help fix my mom's memory, right? She can't remember how to do just about anything she used to do, and I think she's starting to forget who people are." Which of the following is the most appropriate response made by the nurse? A. "Our goal is to help your mother function at her highest level of cognitive ability." B. "There is no hope at this point in the disease. She will only get worse no matter what we do." C. "Our goal is to get your mother functioning at the level she was before her diagnosis!" D. "I think it's time for you to accept these changes and move on."

A. "Our goal is to help your mother function at her highest level of cognitive ability."

A student nurse is caring for a patient with Parkinson's Disease that has tremors. Select the options that requires further teaching about tremors experienced in this disease. A. The tremors are most likely to occur with purposeful movements. B. A common term used to describe the tremors in the hands and fingers is called "pin rolling." C. Tremors are one of the most common signs and symptoms in Parkinson's disease. D. Tremors in this disease can occur in the hands, fingers, arms, legs, lips, and tongue.

A. The tremors are most likely to occur with purposeful movements.

A 68-year-old patient has been taking opioids for chronic osteoarthritis. He arrives at the ER presenting with respirations of 8 per minute, very confused and groggy. His arterial blood gases are: pH 7.25 PaCO2 of 70 and HC03 of 28, what is the most likely diagnosis for this patient? A) Respiratory Alkalosis B) Respiratory Acidosis C) Hypoglycemia D) Epistaxis

B Respiratory alkalosis occurs when pH raises above 7.35. Respiratory Acidosis occurs when retaining PaCO2. Normal respirations for an adult are between 12-20. If hypo ventilation occurs, the lack of breathing out CO2 causes it to accumulate in the blood and rise above the normal of 45. Normal pH is between 7.35 and 7.45. a pH below 7.35 is acidic, causing respiratory acidosis. Hypoglycemia occurs with low blood glucose levels. Epistaxis is a nosebleed.

Which of the following is not a s/s of diabetic ketoacidosis? a) fatigue b) oliguria/anuria c) abdominal pain d) dry mucus membrane

B) Oliguria/Anuria. In DKA you have polyuria (high urinary output) due to increased glucose in the urine, the opposite is oliguria (little) and anuria (none). Fatigue, abdominal pain, and dry mucus membranes are all symptoms of DKA.

The patient's labs are back, indicating metabolic alkalosis. When reviewing the patient's medication list, which medication should be discontinued to avoid potassium loss? a. Aldactone b. Thiazides c. Sodium Bicarbonate d. Diamox

B) Thiazide Diuretics Thiazide diuretics are potassium wasting diuretics; if potassium becomes low in patients taking these medications, either potassium must be supplemented or the medication must be stopped or changed

The provider has ordered a bolus of 1L of 0.9% NS. The nurse should question this order for which of the following patients? Select all that apply. a. 44 y/o male with Type 1 DM b. 78 y/o male with CHF c. 23 y/o male with severe dehydration d. 53 y/o female, post-op hysterectomy e. 67 y/o female with stage 3 renal failure

B,E. Fluid volume overload can be caused with isotonic solutions. These solutions must be used with caution in patients with cardiac and renal disease.

When reviewing several cases, you are trying to determine which person is most at risk for developing Alzheimer's Disease. Which one of these patients is most at risk? A. 62 year old white man with pancreatic cancer, and father had AD B. 68 year old African American women, with type 2 diabetes C. 26 year old professional football player, Derrick Henry D. 45 year old white female, who is morbidly obese

B. African American are about twice as likely to have AD and other dementias as older whites. Nearly two thirds of people with AD are women, and diabetes dramatically increases a persons risk for developing diabetes. This person is most at risk.

Which class of drugs is the preferred choice for patients that have had an MI or Heart Failure? A. ACE Inhibitors B. B-Adrenergic blockers C. Calcium Channel Blockers D. Dihydropyridines

B. B-Adrenergic blockers

A 54-year-old male patient has just come into the Emergency room and seemed very confused and had slurred speech. Pt is complaining of severe headache, and troubles moving the extremities on his left side. What is the primary nurse's main concern? A. Check pt vital signs and see if this is an HTN emergency. B. Get this pt to a CT scanner STAT, they're having a stroke. C. Check BAC, there is another drunk in the ER. D. Get an ECG and check cardiac rhythm STAT E. Have the PT wait patiently in the waiting room until their turn is up

B. Get this pt to a CT scanner STAT, they're having a stroke.

The nurse is caring for a patient recently diagnosed with hypertension. The patient has attempted non-pharmacological lifestyle changes for 2 weeks with a very minimal reduction in blood pressure. Which nursing intervention is appropriate for this patient? A. Anticipate pharmacological treatment B. Encourage patient to continue with the lifestyle changes and reevaluate in 2-3 weeks C. Notify health care provider immediately D. Encourage patient to disregard the lifestyle changes and resume previous lifestyle

B. Non-pharmacological approaches that do not decrease blood pressure after 1-3 months may require pharmacological. This patient has only adjusted lifestyle behaviors for two weeks and should continue and be reevaluated after a couple more weeks.

The nurse is planning care for a patient with respiratory alkalosis. Which outcome would be most appropriate for this patient? A. The patient will have no further vomiting B. The patient will restore a normal respiratory rate and rhythm C. The patient will report a pain level of 3/10 D. The patient's incision will remain infection free

B. The patient will restore a normal respiratory rate and rhythm Rationale: The most important priority for the nurse in this situation is to restore a normal respiratory rate and rhythm because controlled breathing is essential for a patient with respiratory alkalosis. No further vomiting does not apply to this situation, along with the patient's incision remaining infection free. Pain control is important, but normal respiratory rates and rhythm are top priority.

Which ED patient is most likely to be diagnosed with DKA? a) A 65yo man with BG of 720 mg/dL and pH of 7.40 who felt okay yesterday but has poor skin turgor and dry oral mucosa. He has recently been prescribed prednisone for ulcerative colitis and hasn't been able to check his BG in a few days because he lost his glucose meter. b) A 35 yo woman with a BG of 150 mg/dL, pH of 7.37 and ketones 3+ in her urine. She is awaiting an ortho consult for a possible metatarsal stress fracture acquired trying to top her personal best trail running at Percy Warner. She has been harassing you about the lack of carb-free cafeteria options if she is going to be here much longer, because she spilled half of her post workout avocado smoothie trying to drive herself here. c) A 21 yo man with a BG of 350mg/dL and pH of 7.29. He recently went to Cancun for spring break 4 weeks after being diagnosed with DM Type 1. He swears he didn't contract the Rona, but he did wind up with a nasty Giardia infection after swallowing a mouthful of water swimming in a cenote. He also only brought 4 days' worth of insulin for a week long trip so he had been "rationing it" and supplementing with shots of tequila since they told him booze would lower his blood sugar. d) A 45 yo woman newly diagnosed with type 2 DM whose BMI is 29 who has been working out with a trainer 5 days a week since her diagnosis. She usually eats before and after each training session but forgot today and passed out doing burpees.

C) 21yo spring breaker Type 1, acidic pH, poor disease/BG management leaving insulin at home. Infections also increase risk of hyperglycemia

Kussmaul breathing is very often seen in patients with ____________; it is a compensatory measure by the body to combat __________ a) DKA; respiratory acidosis b) DKA; respiratory alkalosis c) DKA; metabolic acidosis d) DKA; metabolic alkalosis e) HHNS; respiratory acidosis f) HHNS; respiratory alkalosis g) HHNS; metabolic acidosis h) HHNS; metabolic alkalosis

C) DKA, metabolic acidosis. Kussmaul breathing increases the exhalation of CO2 to compensate for an acidic state created by the metabolic production of ketones. Kussmaul breathing is not a classic symptom of HHNS (no ketones)

Your patient with HHS was admitted to bring down a BG of 750 mg/dL. Treatment went well and the patient is preparing for discharge. As you are documenting in the patient's chart in the room, you ask the NSCC nursing student to get one last Accucheck and then pull the patient's IV. The student gets really excited because she pulled 2 IVs yesterday, and it went really well. Once the patient's IV is pulled, the student asks the patient for his preferred finger to stick and only then realizes that the patient is no longer conscious, diaphoretic, looks pale, and feels cool. A quick read reveals a BG of 50. What is the priority action by the nurse? a) sternal rub the patient until they are awake and administer 15g of OJ or dextrose oral liquid PO. b) quickly start a new line like the IV wizard that you are and push a 35 mL 50% dextrose bolus. c) give glucagon IM into the patient's deltoid or anterior thigh and roll them onto their side to prevent aspiration. d) recheck the patient's BG because he really shouldn't be symptomatic at 50

C) Glucagon IM. You no longer have access and can't be sure you'd get access quickly enough to restick them. Even if they respond to a sternal rub, it's still risky to give them anything PO. They could very well be symptomatic at 55 so don't waste time rechecking. Nausea is a common reaction of glucagon injection so be sure to prevent aspiration by rolling the patient to the side.

Which of the following is NOT a cause of metabolic acidosis? A. Aspirin toxicity B. Ileostomy C. Hyperaldosteronism D. Carbonic anhydrase inhibitors

C) Hyperaldosteronism Hyperaldosteronism is not a cause of metabolic acidosis. The remaining answers can cause metabolic acidosis.

A post op patient with an NG tube has just arrived to the unit. Which acid base disorder should the nurse be monitoring for in this patient? A. Respiratory Alkalosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

C) Metabolic Alkalosis Suctioning of the stomach can remove too much acid from the body resulting in shift to metabolic alkalosis

Billy's grandfather has been vomiting every 1 2 hours for the past 3 days. He is lethargic, weak and showing signs of muscles pain and aches. Billy recognizes his grandfather lips and mouth are very dry and cracking and checks his cap refill and its >5 seconds. Billy takes his grandfather to the hospital where he's diagnosed to have gastritis and hypovolemia. The nurse pulls ABGs for lab analysis and the results are pH 7.5, PaCO2 40mmHg, PaO2 85mmHg, and HCO3 34mmol/L. What acid base imbalance is Billy's Grandfather experiencing? A. Uncompensated respiratory alkalosis B. Partially compensated respiratory acidosis C. Uncompensated Metabolic Alkalosis D. Partially Compensated Metabolic Alkalosis

C) Uncompensated Metabolic Alkalosis The primary disorder is high HCO3- . CO2 is the catalyst for breathing in healthy individuals; generally hypoventilation doesn't occur in compensation for metabolic alkalosis.

Mr. B brings Mrs. B to the ER complaining that she is extremely confused, irritable, and has been vomiting for three days. What electrolyte imbalance should be reported to the HCP immediately? a. Calcium 9.0 b. Magnesium 1.8 c. Potassium 7.5 d. Sodium 140

C. Potassium 7.5 Potassium 7.5; normal range is 3.5-5.0. High potassium will cause confusion, irritability, and vomiting. All other electrolytes are in normal range.

A patient comes in to the ER having a stroke. After assessing effects of a stroke, which diagnosis is a priority nursing diagnosis? A. Risk for aspiration related to decreased gag and swallowing reflexes B. Impaired verbal communication related to aphasia evidenced by stuttering and spoken words not easily understandable by the nurse. C. Impaired physical mobility related to neuromuscular and cognitive impairment and decreased muscle strength and control evidenced by right sided weakness and inability to ambulate safely D. Situational low self-esteem related to actual loss of function and altered body image evidenced by stroke, impaired physical mobility, and symptoms related to anxiety and depression.

C. Priority is ABC's and safety. Risk for aspiration is only a risk; it has not already occurred. Verbal communication and low self-esteem are not priority nursing diagnoses. They can wait to be addressed until ABC's and Safety have been addressed. Safety is priority in this question. Impaired physical mobility can lead to injury if the patient tries to reposition/ambulate without assistance. Provide a safe environment for the patient first, then assess the risk for aspiration.

The nurse is educating a patient who recently experienced a transient ischemic attack (TIA). The patient is very interested in finding out the most important steps they can take to prevent a stroke from happening in the future. The knowledgeable nurse knows that THE MOST IMPORTANT risk factor to address in the prevention of a stroke is: A. diabetes mellitus B. smoking and drinking C. hypertension D. hypotension E. hyperlipidemia

C. hypertension

A patient arrived at the ED confused with right-sided weakness and is being prepped for a CT scan. What statement made by the nurse requires further teaching? A. "You will need to remove any metal from your body before the scan." B. "CT scans are painless. The worst part is having your blood drawn to run labs before we can start." C. "The images from a CT scan can show us why you may be experiencing these symptoms." D. "The CT machines can be very loud and may induce some anxiety."

D No correct answer on the document, you'll have to confirm the correct answer.

A patient presents to the Emergency Department with shortness of breath. Their blood gases are pH 7.31, PaCO2 52, PaO2 88, HCO3 25. The nurse notes wheezing upon auscultation. Which medication should the nurse be prepared to administer first? A) Oral aspirin B) IV morphine C) oral corticosteroid D) nebulized albuterol

D) nebulized albuterol The patient's ABGs indicate respiratory acidosis when combined with wheezing is indicative of hypoventilation due to an obstructive pulmonary disease. In order to correct the respiratory acidosis, the underlying problem needs to be corrected. Of the available options, nebulized albuterol, the bronchodilator, is the first line medication to treat the bronchoconstriction. Oral corticosteroids could be used if initial treatments are unsuccessful. Aspirin overdose can result in hyperventilation. IV morphine would potentially decrease the respiratory rate and therefore further exacerbate the problem.

The nurse is teaching a patient about lifestyle modifications that will help to decrease blood pressure. The nurse knows that teaching has been effective if the patient states (Select all that apply) A. I will take a brisk walk more than 5 days every week. B. I will start the prescribed weight reduction plan. C. I will increase my sodium intake by adding salt to most foods I eat. D. I will begin a smoking cessation program. E. I will only drink 3 beers every day.

No correct answer provided.

You are a nurse working on a cardiac floor. On reviewing your patient's medical records, which patient is most likely at risk for a fluid volume deficit? a. A patient with an ileostomy b. A patient with heart failure c. A patient receiving frequent wound irrigations. d. A patient on long term corticosteroid therapy.

a. A patient with an ileostomy A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, draining fistulas, and the presence of an ileostomy or colostomy. All other options would put the client at risk for fluid volume excess.

Mrs. Jackson was admitted to the ED last night with hyponatremia, she has a poor diet and is malnourished. She drinks 10 glasses of water a day and upon admission she was given the wrong IV solution (hypotonic). Mrs .Jackson is really confused now and vomiting. She complains her head huts. Her sodium is dropping rapidly. What is causing her sudden symptoms? a. Decrease in ICP b. Potassium level of 3.5 c. Increase in ICP d. Sodium level of 140 mEq/L

c. Increase in ICP Mrs. Jackson has an excessive amount of fluid and not enough sodium; she was given the wrong IV fluids to cause her to be even more fluid overloaded. This results in cerebral edema causing an increase in ICP, the brain has nowhere to go causing the brain to herniate. She is at high risk of death and will need immediate treatment. (Patient will complain of headache, nausea, vomiting, lethargy, confusion, and if sodium levels drop to quickly coma or death can occur)(water enters the brain cells causing them to swell, because the brain is enclosed in bony skull it cannot expand, brain will be compressed)

A patient with Cushing's Syndrome has been experiencing an infection and has a fever of 102F. On assessment, you find the patient to be confused, restless, has dry mucous membranes and flushed skin. Which finding below correlates with the presentation of this patient? a. Sodium level of 144 b. Sodium level of 115 c. Sodium level of 170 d. Sodium level of 135

c. Sodium level of 170 The levels presented in option A, B and D are either hyponatremia or normal sodium ranges. The assessment information presented in the question are signs of hypernatremia. The correct answer is C. Hypernatremia is a serum sodium level that exceeds 145 mEq/L.