Final (NCLEX questions)

A 10-month-old child is brought to the emergency department because of difficulty breathing. The child is running a temperature, and a high-pitched musical squeak is audible. What could this indicate? A) Croup inspiratory stridor B) Paralytic C) Bowel obstruction D) Dehydration

A) Croup inspiratory stridor

You are assessing a 5-year-old who has been admitted with an acute respiratory infection. You review the chart and see the child has cystic fibrosis. What is the priority for assessment? A) Modifying the child's diet B) Opening and maintaining a patent airway C) Checking levels of pancreatic enzymes D) Giving antibiotics to the child

B) Opening and maintaining a patent airway

You are assessing a 2-year-old child, and you count more than 60 respirations. What should you do? A) Ask the child if he has been playing. B) Nothing--this is normal. C) Write this information on the chart. D) Immediately tell the nurse in charge and/or the doctor.

D) Immediately tell the nurse in charge and/or the doctor. If the respiratory rate is greater than 60, report this finding immediately to the nurse in charge and/or the doctor. At a respiratory rate of 60 or greater, very little oxygen can get to the alveoli for gas exchange.

A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? a) client's temperature b) expiration date on the bag c) time of last dressing change d) tightness of tubing connections

a) client's temperature Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess.

At 8 am, a nurse checks the amount of solution left in a parenteral nutrition (PN) infusion bag for an assigned client. It is a 3000 ml bag with 1000 ml remaining. The solution is running at a rate of 100 ml/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at: a) noon b) 2 pm c) 4 pm d) 8 pm

a) noon Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. The nurse always should adhere to specific agency policies.

A school-age child with CF asks the nurse what sports she can be involved in as she becomes older. Which of the following activities would be most appropriate for the nurse to suggest? a) swimming b) track c) baseball d) javelin throwing

a) swimming - swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport.

A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza? a. Septicemia b. Pneumonia c. Meningitis d. Pulmonary edema

b. Pneumonia Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection.

A client is receiving nutrition by means of parenteral nutrition (PN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia? a) fever, weak pulse, and thirst b) nausea, vomiting, and oliguria c) sweating, chills, and abdominal pain d) weakness, thirst, and increased urine output

d) weakness, thirst, and increased urine output The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, and coma, when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately.

A 5-month-old child has been diagnosed with sickle cell anemia. A blood transfusion has been given along with analgesics to control pain. To decrease the chance of a sickle cell crisis, the child's diet should be changed. What kind of diet should the child follow? A) Low in fluids and high in protein B) High in calories and protein C) Low in calories and protein D) High in fluids and low in protein

B) High in calories and protein A diet high in calories and protein with adequate fluid intake can decrease the chance of sickle cell crisis. Because chronically ill children are at greater risk for infection, and because infection can stimulate crisis, it is essential to prevent infection. Immunizations should be kept up to date, and the child should avoid contact with infected persons. Frequent hand washing is a must.

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a. Hypoxia b. Delirium c. Hyperventilation d. Semiconsciousness

a. Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate.

Nurse Celine is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, the nurse should instruct the client to: a. Avoid chocolate and cheese b. Take frequent naps c. Take the medication with milk d. Avoid walking without assistance

a. Avoid chocolate and cheese Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese may precipitate hypertensive crisis.

Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client's arterial blood oxygen saturation? a. Endotracheal suctioning b. Encouragement of coughing c. Use of cooling blanket d. Incentive spirometry

a. Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level.

Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? a. It helps prevent early airway collapse. b. It increases inspiratory muscle strength c. It decreases use of accessory breathing muscles. d. It prolongs the inspiratory phase of respiration.

a. It helps prevent early airway collapse. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress.

For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care? a. Measuring and documenting the drainage in the collection chamber b. Maintaining continuous bubbling in the water-seal chamber c. Keeping the collection chamber at chest level d. Stripping the chest tube every hour

a. Measuring and documenting the drainage in the collection chamber The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased).

The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a. Place the end of the chest tube in a container of sterile saline. b. Apply an occlusive dressing and notify the physician. c. Clamp the chest tube immediately. d. Secure the chest tube with tape.

a. Place the end of the chest tube in a container of sterile saline. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected.

Nurse Murphy administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? a. Respiratory rate of 22 breaths/minute b. Dilated and reactive pupils c. Urine output of 40 ml/hour d. Heart rate of 100 beats/minute

a. Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation.

A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that: a. vancomycin should be infused over 60 to 90 minutes in a large volume of fluid. b. vancomycin may cause irreversible neutropenia. c. vancomycin should be administered rapidly in a large volume of fluid. d. vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

a. vancomycin should be infused over 60 to 90 minutes in a large volume of fluid. To avoid a hypotensive reaction from rapid I.V. administration, the nurse should infuse vancomycin slowly, over 60 to 90 minutes, in a large volume of fluid.

A nurse is preparing to hang fat emulsion (lipids) and notes that the fat globules are visible at the top of the solution. The nurse takes which of the following actions? a) rolls the bottle of solution gently b) obtains a different bottle of solution c) shakes the bottle of solution vigorously d) runs the bottle of solution under warm water

b) obtains a different bottle of solution The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy.

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a. Immediately before a meal b. At least 2 hours after a meal c. When bronchospasms occur d. When secretions have mobilized

b. At least 2 hours after a meal The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat.

Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review? a. Fluid intake for the last 24 hours b. Baseline arterial blood gas (ABG) levels c. Prior outcomes of weaning d. Electrocardiogram (ECG) results

b. Baseline arterial blood gas (ABG) levels Before weaning a client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure.

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. b. Instruct the client to breathe into a paper bag. c. Offer the client fluids frequently. d. Administer prescribed supplemental oxygen.

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

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a. Simple mask b. Non-rebreather mask c. Face tent d. Nasal cannula

b. Non-rebreather mask A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%

Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include: a. drinking more than 1,500 ml of fluid daily. b. being overweight. c. eating a high-protein snack at bedtime. d. eating more than three large meals a day.

b. being overweight. Conditions that increase oxygen demands include obesity, smoking, exposure to temperature extremes, and stress.

The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a. helping him communicate. b. keeping his airway patent. c. encouraging him to perform activities of daily living. d. preventing him from developing an infection.

b. keeping his airway patent. Maintaining a patent airway is the most basic and critical human need. All other interventions are important to the client's well-being but not as important as having sufficient oxygen to breathe.

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Narcotic overdose

c. Extreme anxiety Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, and injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication.

A 2 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? a. Use aseptic technique during dressing changes b. Maintain central line catheter integrity c. Monitor serum glucose levels d. Check results of liver function tests

c. Monitor serum glucose levels Monitor serum glucose levels. Hyperglycemia may occur during the first day or 2 as the child adapts to the high-glucose load of the TPN solution.

A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. pH b. Bicarbonate (HCO3-) c. Partial pressure of arterial oxygen (PaO2) d. Partial pressure of arterial carbon dioxide (PaCO2)

c. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value.

When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? a. Record the number of stools per day b. Maintain strict intake and output records c. Sterile technique for dressing change at IV site d. Monitor for cardiac arrhythmias

c. Sterile technique for dressing change at IV site Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion site.

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? a. Restricting fluid intake to 1,000 ml/day b. Enforcing absolute bed rest c. Teaching the client how to perform controlled coughing d. Administering prescribed sedatives regularly and in large amounts

c. Teaching the client how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions

Pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the client to drink three glasses of fluid daily b. Keeping the client in semi-Fowler's position c. Using a high-flow Venturi mask to deliver oxygen as prescribed d. Administering a sedative as prescribed

c. Using a high-flow Venturi mask to deliver oxygen as prescribed The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately.

When teaching the parents of an older infant with CF (cystic fibrosis) about the type of diet the child should consume, which of the following would be most appropriate? a) low protein diet b) high fat diet c) low carbohydrate diet d) high calorie diet

d) high calorie diet - CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction, a moderate fat, high calorie diet is indicated.

A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first? a) obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position

d) place the child in knee-to-chest position - the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea.

A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which most essential action during the tubing change? a) breathe normally b) turn the head to the right c) exhale slowly and evenly d) take a deep breath, hold it, and bear down

d) take a deep breath, hold it, and bear down The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down.

Nurse Jamie is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? a. Temperature of 37.5 degrees Celsius b. Urine output of 300 cc in 4 hours c. Poor skin turgor d. Blood glucose of 350 mg/dl

d. Blood glucose of 350 mg/dl Total parenteral nutrition formulas contain dextrose in concentrations of 10% or greater to supply 20% to 50% of the total calories. Blood glucose levels should be checked every 4 to 6 hours. A sliding scale dose of insulin may be ordered to maintain the blood glucose level below 200mg/dl.

On arrival at the intensive care unit, a critically ill female client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a. Fever b. Tachypnea c. Tachycardia d. Hypotension

d. Hypotension Hypotension, hypothermia, and vasoconstriction may alter pulse oximetry values by reducing arterial blood flow.

A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? a. Activity intolerance related to fatigue b. Anxiety related to actual threat to health status c. Risk for infection related to retained secretions d. Impaired gas exchange related to airflow obstruction

d. Impaired gas exchange related to airflow obstruction A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis.

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. alprazolam (Xanax). b. propranolol (Inderal) c. morphine. d. albuterol (Proventil).

d. albuterol (Proventil). The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished.

A two-year-old child with congestive heart failure has been receiving digoxin for one week. The nurse needs to recognize that an early sign of digitalis toxicity is: a. bradypnea. b. failure to thrive. c. tachycardia. d. vomiting.

d. vomiting.