Practice questions for NCLEX
A 17 year old adolescent and girlfriend are being treated in the emergency room for moderate injuries following a motorcycle accident. The adolescent is unconscious and will need surgery but family cannot be located to give consent. What does the nurse know is true about informed consent? 1. Informed consent can be provided by the girlfriend. 2. Consent is not necessary in this particular situation. 3. Surgery must be delayed until the family is located. 4. Surgery cannot be done while client is unconscious.
#3 is correct. In a situation where a 17 year old adolescent client is unconscious, the parents as 'next of kin' must provide consent. Since the parents cannot yet be located, the surgery will be delayed until consent is obtained. 1 is obviously wrong 2--consent wouldn't be necessary if the client sustained life-threatening injuries or an injury that might cause him/her to lose a limb 4--this statement infers that the client must awaken to provide consent before being anesthetized, which is false.
Metabolic Acidosis is commonly caused by these four things...
-DKA (explanation in another question) -Starvation (explanation in another question) -Renal Failure -Severe diarrhea (lots of bicarb in the GI tract, too much lost with diarrhea)
Respiratory Acidosis is caused by stuff that causes hypoventilation or hyperventilation, which one? Some causes are....? Ways to fix it are...?
-Hypoventilation means the body isn't breathing in enough oxygen and releasing enough CO2. -Some causes are: sleeping pills or narcotics, pneumothorax or collapsed lung, or pneumonia (poor gas exchange with pneumonia.) -Ways to fix it: breathe!!! incentive spirometry, TCDB, elevate the HOB, treat the pneumonia, suctioning, chest tube(s) or pneumothorax
A pt who is suspected to have hyperthyroidism is interested in being educated on his potential diagnosis. Which of the following statements are true? 1) To diagnose your condition, we will do some blood tests and a thyroid scan. You must stop taking any medication that contains iodine at least one week prior to the scan; this includes your heart medication, Amiodarone. 2) One way we can confirm hyperthyroidism is if your blood contains low amounts of calcitonin and high amounts of T4, or Thyroxine. 3) The doctor may order potassium iodine to help decrease the size of your thyroid gland. Be sure to take it with water and on an empty stomach. 4) Be sure to let us know if you feel any pressure in your throat after the thyroidectomy. 5) Before and after the thyroidectomy, be sure to eat foods that are high in protein.
1) CORRECT 2) INCORRECT- this pt's blood would contain high amounts of calcitonin and thyroxine, both are produced by the thyroid gland...but their TSH level would be low 3) INCORRECT- the statement is true in that potassium iodine decreases the size of the thyroid, but it should be taken with milk or juice because it stains teeth. 4) CORRECT- because if the parathyroid gland is accidentally taken out during the thyroidectomy, the patient will become hypocalcemic, so their muscles will tighten up, including their airway 5) INCORRECT- the patient should eat foods with lots of calories because they are malnourished and need them to heal and for energy
Jan's new patient, Fat Albert, has just been diagnosed with hypothyroidism. What are some things she should keep in mind when caring for this patient? 1) I need to monitor Albert for signs of a heart attack when he first starts taking his Levo. 2) I should make sure Fat Albert takes his Levo with breakfast so it doesn't burn his stomach. 3) I know he will be cold, so I'll go ahead and take a heated blanket to him. 4) I should probably put at least two chucks pads underneath him because he'll likely have diarrhea.
1) CORRECT-because most hypothyroid patients have CAD, worry about an MI when they first begin these meds 2) INCORRECT-take on an empty stomach 3) INCORRECT- these patients wont be able to feel if they're being burned by the blanket 4) INCORRECT- these patients will likely be constipated
Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? 1) Nonmaleficence 2) Beneficence 3) Justice 4) Fidelity
1) CORRECT: Nonmaleficence means to do no harm. Reporting a medical error would prevent the patient from experiencing further complications. 2) Beneficence refers to doing good...like being compassionate or kind to patients. 3) Justice refers to equal distribution of resources. Triage in the ED is an example of justice. 4) Fidelity refers to telling the truth. For example, if the patient asked the nurse if there was a medication error, telling the truthful answer would demonstrate fidelity.
Select all of the answers that best describe parathyroidism. 1) Any parathyroid problems are going to deal with calcium. 2) Jan's body doesn't make enough PTH. She's risks breaking a bone. 3) #1 nursing intervention for pt following partial parathyroidectomy is monitoring for rigid muscles 4) Pts with hypoparathyroidism are prone to getting kidney stones. 5) The parathyroid gland relies on the presence of Vitamin D to work. 6) A pt who has hypoparathyroidism may have muscle spasms, arrhythmias, and convulsions.
1) true 2) false---low PTH = low serum calcium, meaning calcium is staying in the bones 3) true---hypocalcemia= tight rigid muscles, including their airway 4) false---Pts with hyperparathyroidism are prone to getting kidney stones. 5) true 6) true---remember CATS (convulsions, arrhythmias, tetany, and stridor)
Which of the following are true regarding a patient who has just had a Total Laryngectomy? 1. Patients will have a temporary tracheostomy or laryngotomy because the entire larynx, including the epiglottis, is removed during surgery. 2. Patients will be NPO status to protect the suture line. 3. Patients should be positioned 35*-45* postop. 4. Patients cannot swim or talk without assistance.
1. INCORRECT---these patients will have a permanent trach or laryngotomy 2. INCORRECT---These patients will have an NG Tube inserted to prevent peristalsys. NPO patients tend to get pneumonia. 3. CORRECT---never position them high-fowlers or supine 4. CORRECT---Patients cannot submerge themselves in water and they must use a Blom-Singer device to speak.
A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be: A. 6,080 mL B. 9,120 mL C. 12,160 mL D. 15,180 mL
12,160
A patient has burns on the front of both arms and her entire chest above her costal margin. What is the most accurate estimate of the amount of body surface burned?
18%
The charge nurse in a psychiatric facility is assigning morning tasks to an unlicensed assistive personnel (UAP). What task should the nurse instruct the UAP to complete first? 1. Accompany client off unit to smoking area. 2. Obtain a morning weight on anorexic client. 3. Assist a client who is depressed to get out of bed. 4. Prepare the day room for group breakfast.
2
To avoid reflux, the pt with GERD should not eat a meal within ______ hours of bedtime
2
Which patient should be assigned to the LPN under the supervision of the RN team leader? 1) 51 yo who has just undergone bilateral adrenalectomy 2) 83 yo with Type 2 DM + COPD 3) 38 yo with MI preparing for discharge 4) 72 yo with mental status changes admitted from a long-term facility
2 is correct LPNs should receive uncomplicated, stable patients. The pt with MI needs complex teaching prior to discharge.
A client weighing 235 lbs has a 30% TBSA burn. The HCP's prescription is: titrate IV fluids to maintain urinary output at 0.5 ml/kg/hr. What is the desired output?
235 lbs / 2.2 =106.8 kg 106.8 X 0.5 =53.409 53 ml/hr
Which of the following are s/s of Metabolic Acidosis? 1. Bradypnea 2. Tachypnea 3. Muscle weakness 4. Muscle tension 5. Arrhythmias 6. Kussmaul Respirations
2: because the pt is try to remove excess CO2 3: because the pt has hyperkalemia 5: because the pt has hyperkalemia 6: hallmark sign of Metabolic Acidosis
What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches
3, 5, 6
An 21 year old male fell asleep by the pool for 5 hours. He has bright red burns from on his neck down to his ankles. What percentage of his anterior body is burned?
45%
A 17 year old has a second degree circumferential burn on his left lower leg and foot. What percentage of body surface area is burned?
9%
Which of the following are common in patients with adrenal hypofunction? 1) hyperkalemia 2) hypertension 3) hyponatremia 4) hypoglycemia 5) hyperpigmentation
Adrenal hypofunction = too many hormones!!! 1) False.....too much aldosterone= too much sodium and water retained and too much potassium lost. 2) True 3) False....too much aldosterone= too much sodium and water 4) False...Cushing's pts are normally hyperglycemic because of excess glucocorticoids 5) False....hyperpigmentation is typical of Addison's. Cushing's pts have thin and striae
The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? A) Cover the burn with ice and secure with a towel. B) Apply butter to the area that is burned. C) Immerse the child in a cool bath. D) Avoid touching the burned area and seek medical attention.
After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure.
Which hormones are secreted soon after a pt is burned? 1. Aldosterone 2. ANP (Atrial Natriuretic Peptide) 3. ADH 4. Epinephrine
Correct: 1, 3, and 4 Aldosterone and ADH are secreted to retain water and sodium (only aldosterone retains sodium) to make blood volume increase. Burns make the body vasodilate. Epinephrine is a vasoconstrictor and is used to compensate for low blood pressure.
Which of the following are pathophysiological changes that occur within the first 24 hours a pt is burned? 1. Hypervolemia 2. Hypovolemia 3. Tachycardia 4. Bradycardia 5. Decreased cardiac output 6. Increased cardiac output 7. Hypertension 8. Hypotension
Correct: 2: Hypovolemia/Fluid volume deficit: increased capillary permeability allows plasma to seep out of the vessels 3: Tachycardia: anytime a pt has a fluid volume deficit, the heart will compensate by beating faster 5: cardiac output decreases because there's less (fluid) volume to pump 8: Hypotension occurs...low volume, low pressure
A client has a total laryngectomy with a permanent tracheostomy. The nurse is planning nutritional intake for the next three days. Which of the following would be necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration. 4. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct: 1 Tube feedings are administered through an NG tube for these patients because it helps protect the suture line (peristalsis can disrupt the suture line) FYI: Making these patients NPO status increases their risk for pneumonia.
Which nursing statements about a client reflect correct documentation in the hospital medical record? 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.
Correct: 1, 2
The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which client would be appropriate for the nurse to assign to the LPN/VN? 1. In Bucks traction requiring frequent pain medication 2. 24 hours post appendectomy 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM 4. Admitted 6 hours ago in adrenal insufficiency 5. In diabetic ketoacidosis receiving IV insulin
Correct: 1, 2, 3 LPNs should receive patients whose condition is stable and predictive.
The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? 1. "I do not think I can continue working." 2. "My husband has taken over the house cleaning and cooking." 3. "I fear I am dying." 4. "I have an "uneasy" feeling most of the time." 5. "Most of the time I feel very 'down and blue'."
Correct: 1, 2, 3, 4 The inability to maintain employment is of concern to most clients who have been used to working. With a chronic illness, the client is unlikely to be able to return to work. Anxiety related to role strain is common. The client may not be able to perform the duties that she once did, thus causing others to have to assume their roles. Death is a possible outcome if transplant does not occur. Fear may be a later diagnosis as the client's condition deteriorates. Clients with anxiety often report feeling uneasy or on edge.
The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse has just completed a 12 hour shift. What options would be appropriate for the nurse to take? 1. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 2. Suggest splitting the shift with another nurse. 3. Accept assignment, documenting personal concerns regarding work conditions. 4. Refuse the overtime assignment, being prepared for disciplinary action. 5. Simply accept the assignment since overtime is mandatory.
Correct: 1, 2, 3, 4...all are options the nurse has
A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Increase protein rich foods in the diet. 4. Cut fingernails short 5. Provide mouth care prior to meals
Correct: 1, 2, 4, 5 Why do we provide mouth care *prior* to meals? Uremic halitosis occurs from a build-up of urea, which produces a metallic taste. Mouth care before meals will eliminate that taste.
The nurse manager is developing a new yearly evaluation form for staff. What statements should the nurse manager include which would most likely improve staff outcomes? 1. "How often do you need help to finish assignments?" 2. "Are there any new skills you feel capable to learn?" 3. "Describe how you organize your daily assignments." 4. "Which tasks are most difficult for you to complete?" 5. "Explain any new goals you would like to achieve."
Correct: 3, 5 Items that test your ability to be client-centered (in this case, staff-centered) tend to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. The client is the priority.
The nurse is reviewing the plan of care for a client during the first day post-craniotomy. Which actions can the nurse delegate to an experienced LPN/LVN working in the ICU? 1. Determine Glasgow Coma Score. 2. Check endotracheal tube (ET) cuff pressure every shift. 3. Reposition client from side to side every 2 hours. 4. Administer acetaminophen via nasogastric tube for temperature greater than 101ºF (38.3ºC). 5. Monitor intake and output every hour.
Correct: 4, 5 Normally, repositioning can be delegated to LPNs, but since this patient is at risk for increased ICP, an RN should reposition the client
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.
Correct: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection.
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Tumor growth will be controlled by the removal of malignant tissue. d. Tumor size will decrease and this will improve the effects of other therapy.
D: A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective.
The CVP reading of a client with partial thickness burns is 6 mm H2O. The nurse recognizes that the client: A. Needs additional fluids B. Has a normal CVP reading C. May show signs of congestive failure D. Would benefit from a diuretic
Has a normal CVP
Respiratory Alkalosis is caused by stuff that causes hypoventilation or hyperventilation, which one? Some causes are....? Ways to fix it are...?
Hyperventilation causes Resp. Alkalosis. Typically it is caused when a person is hysterical, crying a lot, having a panic attack, etc. -Other causes: aspirin overdose -Ways to fix it: breathe into a paper bag if at home, may have to use light sedation if it at the hospital to decrease the respiratory rate, treat the cause, obtain/monitor ABGs
Which immunizations should high school graduates receive before going to college?
Meningococcal HPV Tdap Influenza
If a client is receiving fluids rapidly, what is a measurement you should monitor to be sure you're not overloading the client?
Monitor CVP (central venous pressure)
A burn patient's diet should be high in _____, ____, & ____.
Protein, calories, and Vitamin C
The pt with GERD should sleep in which position?
Semi-fowlers/fowlers....the pt should sleep sitting up, elevated by six inch blocks and several pillows
Upon insertion of a urinary catheter, the nurse notices there is no urine return. What should be her concern? What should be her next action?
The kidneys either aren't being perfused adequately or are trying to compensate by holding fluids. The nurse should be concerned that the pt is going into renal failure. To check oxygen perfusion, she must obtain an ABG because a pulse ox will not be accurate (carbon monoxide binds to hgb faster than oxygen does.) She may also assess the patient's MAP, which should be between 70-100. A MAP less than 60 means the kidneys are at high risk of not being perfused.
It is time to change the dressings on a burn patient. What does the nurse do to reduce pain and discomfort at this time? A) The nurse lets the patient decide on when to change the dressing. B) The nurse skip's the dressing change if the patient is really uncomfortable. C) The nurse changes dressings as quickly as possible. D) The nurse lets the aide do the painful part of the dressing change.
The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. Letting the patient decide the time of the dressing change lets the patient feel more in control. It doesn't reduce pain and discomfort. The nurse should never skip an ordered dressing change. You never delegate a dressing change on a burn patient.
Why do patients who suffer from starvation or go into DKA commonly have metabolic acidosis?
These patient's body cells are starving for glucose for energy. Without the glucose, the body starts breaking down protein and fat, which produces ketones. KETONES ARE ACIDS.
What ABG results would the nurse expect on a client who has overdosed on aspirin (ASA)?
This ABG result indicates respiratory alkalosis. Aspirin stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off CO2 and causing the pH to increase. Losing CO2 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaCO2 and normal HCO3.
With Metabolic Acidosis, what organ is sick? What chemical(s) are causing the problem? To compensate, what will happen to the respiratory rate?
With metabolic acidosis, the kidneys are not working properly. They are retaining too much Hydrogen or are excreting too much bicarb. Too compensate, the lungs will increase RR in order to excrete more CO2, an acid.
When evaluating the burn extremity for the development of compartment syndrome, which signs and symptoms would alert the nurse to the possibility this has developed?? a.The presence of burn eschar that covers the entire lateral surface of the extremity. b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses. c. The edema is the area is rapidly dissipating resulting in hypoperfusion to the extremity. d. There is increased discomfort in the affected area.
b. There is evidence of tautness, decreased capillary refill, coolness and decreased pulses.
Paramedics bring in a pt who is non-responsive, has singed facial hair, soot present in his nares, and burns in the throat and upper chest region. What might the HCP do *prophylactically*?
intubate....because the throat will swell, which will make intubation harder if postponed
To confirm a diagnosis of pheochromocytoma, either a VMA (vanillylmandelic acid) test or MN (metanephrine) test must be done to assess catecholamine levels. Prior to the test, the patient should not eat/drink all of the following except which option? 1) Fruit juices 2) Vanilla Coke 3) anything with Vitamin B in it 4) Coffee 5) Strawberries 6) Bananas
the patient should not eat or drink anything with vanilla, caffeine, Vitamin B, bananas, fruit juices because they/it could alter the test results 1) true 2) true 3) true 4) true 5) false 6) true
The pt with GERD should eat foods high in _____ & low in _____.
the pt should eat foods high in protein and low in fat (in an attempt to lose weight)