NCLEX RN TEST BANK FOR
2022 ACTUAL EXAMINATION
PREPARATION.(With
Rationales)
Ref # 4366
The nurse receives a client from the post anesthesia care unit following a left femoralpopliteal bypass graft procedure. Which of the following assessments requires immediate
notification of the health care provider?<\/p>\n\n\n\n
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
Ref # 2446
A woman, who delivered five days ago and who had been diagnosed with
pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask
for advice. She states, “I have had the worst headache for the past two days.
It pounds and by the middle of the afternoon everything I look at looks wavy.
Nothing I have taken helps.” What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the home
The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes. The
client demanded a blanket. How should the nurse respond?
“I see this is frustrating for you. I have a few minutes so let’s talk.”
This is the best response because it gives credence to the client’s feelings and then concerns. To say
“let’s talk” and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client’s feelings. To apologize and not notice the client’s feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client’s verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a right
inguinal orchiectomy. Which option is the priority before the client can be
discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer
(testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with
an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men
will be able to eat regularly when they get home; they should at least tolerate liquids before discharge.
It’s important that the client is able to get up and walk with assistance, but this is not the priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate
priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of
the following should the nurse focus on first?<\/p>\n\n\n\n
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking’s effects result in
reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be
addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG ( Diagnosis
Related Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other
insurance companies often use it as a standard for determining payment. KEYWORDS DRG
diagnosis related group reimbursement
Ref # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce
the most stress at this age? Separation anxiety While a toddler will experience all of the stresses,
separation from parents is the major stressor. Separation anxiety peaks in the toddler years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the
laboratory result indicates a client with partly compensated metabolic acidosis?
PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq\/L.) Compensation means the body is trying
to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory
decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both
males and females. The chloride and sodium results are also WNL.
Ref # 2391
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has
died. Which type of precautions is appropriate to use when performing
postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days
after the client dies. Therefore, contact precautions must still be used. The body should also be labeled
as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves
are required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower
lobectomy. During the repositioning of the client during the first postop check, the
nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the
chest drain system. What is the appropriate nursing action?<\/p>\n\n\n\n
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark color of
the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected
within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the
drainage exceeds 100 mL\/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor
vehicle accident. When assessing the client 30 minutes after admission, the nurse
notes several physical changes. Which finding would require the nurse’s immediate
attention? Tracheal deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build,
collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to
the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency,
requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the
pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would expect
the client to be treated with oral pancreatic enzymes and which type of
diet? High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to
prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for
osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten
intolerance, not CF, needs a gluten-free diet.
Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours
after surgical repair of a fractured femur. The child is crying and reports having
severe pain. The right foot is pale and there is no palpable pulse. What action should
the nurse take first? Notify the health care provider Pain and absence of a pulse within 48-72 hours
after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when
there’s a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle
and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed
immediately; delaying surgery can lead to permanent damage to the extremity.
Ref # 1927 The nurse is examining a 2 year-old child with a tentative diagnosis of
Wilm’s tumor. The nurse would be most concerned about which statement by the
mother? “Urinary output seems to be less over the past two days.”
Wilm’s tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a
recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction.
Increasing abdominal girth is a common finding in Wilm’s tumor, but does not require immediate
intervention by the nurse.
<\/p>\n","protected":false},"excerpt":{"rendered":"
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