NCLEX review Chapter 1, 4
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 30 mm Hg, HCO3 22mEq/L. The nurse analyzes these results as indicating which condition. 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. metabolic alkalosis, uncompensated 4. respiratory acidosis, uncompensated
answer: 2 Use the steps of the nursing process and analyze the values. The question dose not require further assessment; therefore, it is appropriate to move to the next step in the nursing process, analysis. The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. So, you can eliminate options 1 and 3. In an alkalytic condition the pH is elevated. The values identified indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred. Remember that analysis is the second step in the nursing process.
best early or late essential first highest priority immediate initial most most appropriate most important most likely next primary vital
words that indicate the need to prioritze
Ascertain assess check collect determine find out gather identify monitor observe obtain information recognize
words that reflect assessment
The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. photophobia 4. Yellow color perception
Answer: 1 This question addresses the subcategory pharmacological and parental therapies in the client needs category physiological integrity. Note the strategic word, EARLY. Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, vomiting. Neurological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs.
A client is scheduled for angioplasty. The client says to the nurse, "I'm so afraid that it will hurt and will make me worse off then I am." Which response by the nurse is therapeutic? 1. "can you tell me what you understand about the procedure?" 2. "your fears are a sign that you really should have this procedure" 3. Those are very normal fears, but please be assured that everything will be okay" 4. "try not to worry. This is a well-known and easy procedure for the health care provider"
Answer: 1 This question addresses the subcategory caring in the category integrated processes. The correct option is a therapeutic communication technique that explores the client's feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client's fears, provides false reassurance, and puts the client's feelings on hold. Option 4 diminishes the client's feelings by directing attention away from the client and toward the health care provider's importance.
A client with Parkinson's disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. use a wheelchair to move around 2. stand erect and use a cane to ambulate 3. keep the feet close together while ambulating and use a walker 4. consciously think about walking over imaginary lines on the floor
Answer: 4 This question addresses the subcategory basic care and comfort in the client needs category physiological integrity, and addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.
The nurse provides medication instructions to a client about digoxin. Which statement by the client indicates an understanding of its adverse effects? 1. "blurred vision is expected" 2. "if i am nauseated or vomiting, i should stay on liquids and take some liquid antacids" 3. "This medication may cause headache and weakness but that is nothing to worry about" 4. "if my pulse rate drops below 60 beats per minute I should let my health care provider know"
Answer: 4 This question is an example of a positive event query question. Note the words INDICATES AN UNDERSTANDING, and focus on the subject, adverse effects. Additionally, focus on the data provided in the options. Digoxin is a cardiac glycoside and works by increasing contractility of the heart. This medication has a narrow therapeutic range and a major concern is toxicity. Currently, it is considered second-line treatment for heart failure because of its narrow therapeutic range and potential for adverse effects. Adverse effects that indicate toxicity include gastrointestinal disturbances, neurological abnormalities, bradycardia or other cardiac irregularities, and ocular disturbances. If any of these occur, the HCP is notified. Additionally, the client should notify the HCP if the pulse rate drops below 60 beats per minute because serious dysrhythmias are another potential adverse effect of digoxin therapy. Remember to focus on the data provided and note positive event queries.
The nurse has reinforced discharge instructions to a client who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the client indicates a need for further teaching regarding home care measures? 1. "i should use a straight razor to shave under my arms" 2. "i need to be sure that i do not have blood pressures or blood drawn from my right arm" 3. "I should inform all of my other health care providers that i have had this surgical procedure" 4. "i need to be sure to wear thick mitt hand covers or use thick pot holders when i am cooking and touching hot pans"
Answer: 1 This question is an example of a negative event query. Note the strategic words, NEED FOR FURTHER TEACHING. These strategic words indicate that you need to select an option that identifies an incorrect client statement. Recall that edema and infection are concerns with this client due to the removal of lymph nodes in the surgical area. Lymphadenopathy can result and the client needs to be instructed in the measures that will avoid trauma to the affected arm. Recalling that trauma to the affected arm could potentially result in edema and/or infection will direct you to the correct option. Remember to watch for negative event queries.
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? 1. remove the IV 2. Apply a warm compress 3. Check for blood return 4. Measure the area of infiltration
Answer: 1 This question requires that you focus on the data in the question and determine that the client is experiencing an infiltration. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage.
The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse should monitor for which early sign of hypovolemic shock? 1. Sleepiness 2. increased pulse rate 3. increased depth of respiration 4. increased orientation to surroundings
Answer: 2 Note the strategic word, EARLY, in the query and the word JUST in the event. Think about the pathophysiology that occurs in the hypovolemic shock to direct you to the correct option. Restlessness is one of the earliest signs followed by cardiovascular changes (increased heart rate and a decrease in blood pressure). Sleepiness is expected in a client who has just returned from surgery. Although increased depth of respiration s occurs in hypovolemic shock, it is not an early sign. Rather, it occurs as the shock progresses. This is why it is important to recognize the strategic word, EARLY, when you read the question. It requires the ability to discern between early and late signs of impending shock. Increased orientation to surroundings is expected and will occur as the effects of anesthesia resolve. Remember to look for strategic words, in both the event and the query of the question.
A magnetic resonance imagining (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter 2. Remove all metal-containing objects from the client 3. Keep the patient NPO for 6 hours before the test 4. instruct the client in inhalation techniques for the administration of the radioscope
Answer: 2 This question addresses the subcateogry reduction of risk potential in the client needs category physiological integrity, and the nurse's responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices., such as orthopedic hardware, pacemakers, or shrapnel. NPO status is not necessary for an MRI study if the head. The groin may be shaved for an angiogram, and inhalation of the radioscope may be prescribed with other types of scans but is not a part of the procedures for an MRI.
A client with renal insufficiency has a magnesium level of 3.5 mEq/L. On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical Hyperactivity
Answer: 2 This question addresses the subcateogry physiological adaptation in the client needs category physiological integrity. It addresses an alternation in body systems. The normal magnesium level is 1.5 to 2.5 mEq/L. A magnesium level of 3.5mEq/L indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.
The nurse caring for a client experiencing dystocia determines that the priority is which action? 1. Position changes and providing comfort measures 2. Explanations to family members about what is happening to the client 3. Monitoring for changes in the physical condition of the mother and fetus 4. Reinforcement of breathing techniques learned in childbirth preparatory classes
Answer: 3 All the options are correct and would be implemented during the care of this client. Note the strategic word, PRIORITY, and use Maslow's Hierarchy of needs come first. Also, the correct option is the only one that addresses both the mother and the fetus. Remember to use Maslow's Hierarchy of needs theory to prioritize.
The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most helpful for this client? 1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials
Answer: 3 Focus on the subject, increasing bed mobility. Also note the strategic word, MOST. The use of an overhead trapeze is extremely helpful in assisting a client to move about in bed and to get on and off the bedpan. Television and reading materials are helpful in reducing boredom and providing distraction and a fracture bedpan is useful in reducing discomfort with elimination; these items are helpful for a client in traction, but they are not directly related to the subject of the question. Remember to focus on the subject.
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. puzzle 2. toy soldiers 3. large stacking blocks 4. a card game with large pictures
Answer: 3 This question addresses the client needs category health promotion and maintenance and specifically relates to the principles of growth and development of a toddler. Note the strategic word, BEST. Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-aged child.
The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant staphylococcus aureuas (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventialtor, which requires frequent suctioning. The nurse should assemble which necessary protective items entering the client's room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors
Answer: 3 This question addresses the subcategory Safety and infection control in the client needs category safe and effective care environment. It addresses content related to protecting oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client's condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.
A client with a diagnosis of cancer is receiving morphine sulfate for pain. The nurse should employ which priority action in the care of the client? 1. monitor stools 2. encourage fluid intake 3. Monitor urine output 4. Encourage the client to cough and deep breathe
Answer: 4 ABC's airway, breathing, circulation as a guide to direct you to the correct option and note the strategic word, PRIORITY. Recall that morphine sulfate suppresses the cough reflex and the respiratory reflex, and a common adverse effect is respiratory depression. Coughing and deep breathing can assist with ensuring adequate oxygenation since the number of respiration s per minute can potentially be decreased in a client receiving this medication. Although options 1,2, and 3 are components of the plan of care, the correct option addressed airway. Remember to use the ABCS to prioritize.
A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first? 1. Elevate the arm 2. Document the findings 3. Medicate with an additional dose of an opioid 4. Check for paresthesias and paralysis of the right arm
Answer: 4 Note the strategic word, FIRST. Based on the data in the question, determine if an abnormality exists. The question event indicates that the client complains of pain at the wrist when the arm is passively moved. This could indicate an abnormality; therefore, further assessment or intervention is required. Use the steps of the nursing process, remembering that assessment is the first step. The only option that addresses assessment is the correct option. Options 1,2,3 address the implementation step of the nursing process. Also, these options are inaccurate first actions. The arm in a cast should have already been elevated. The client may be experiencing compartment syndrome, a complication following trauma to the extremities and application of a cast. Additional data need to be collected to determine whether this complication is present. Remember that assessment is the first step in the nursing process.
A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. "this will help only if i play music at the same time" 2. "this will work for me only if i am alone in a quiet area" 3. "i need to do this only when i lie down in case i fall asleep" 4. "The best thing about this is that i can use it anywhere anytime"
Answer: 4 This question addresses the client needs category psychosocial integrity and the content addresses coping mechanisms. Guided imagery involves the client creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation techniques or play music with it.
The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. the client who needs to receive subcutaneous insulin before breakfast 2. the client who has a nasogastic tube attached to intermittent suction 3. the client who is 2 days postoperative and is complaining of incisional pain 4. the client who has a blood glucose level of 50 mg/dL and complaints of blurred vision
Answer: 4 This question addresses the subcategory Management of Care in the Client Needs category Safe and Effective Care environment. Note the strategic word, FIRST, so you need to establish priorities by comparing the needs of each client and deciding which need is urgent. The client described in the correct option has a low blood glucose level and symptoms reflective of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1,2,3 have needs that require assessment, their assessments can wait until the client in the correct option is stabilized
