2020 NCLEX-RN TEST PREP: PREVENTING

2020 NCLEX-RN TEST PREP: PREVENTING

RISKS AND COMPLICATIONS (STUDY MODE)

PRACTICE QUESTIONS WITH: ANSWERS &

EXPLANATIONS

1.Which of the following nursing interventions is appropriate for a client who is suffering from a fever?

• Avoid giving the client food
• Increase the client's fluid volume
• Provide oxygen
• All answers are correct

ANSWER B: Interventions for a client who is suffering from a fever include

increasing the client's volume of fluid and providing oxygen. A fever increases the body's metabolism, causing the client to breath at a faster rate and increasing the work of the heart. The client is at risk of fluid loss due to increased respiration and sweating. In some cases, depending on the reason for the fever, the increased work of the heart requires more oxygen to maintain perfusion to the tissues.

2.A client has started sweating profusely due to intense heat. His overall fluid volume is low and he has developed electrolyte imbalance. This client is most

likely suffering from:

• Malignant hyperthermia
• Heat exhaustion
• Heat stroke

• Heat cramps

ANSWER B: Heat exhaustion occurs when a person has enough diaphoresis

that he becomes dehydrated. Intense sweating can cause both fluid and electrolyte imbalances. Untreated heat exhaustion can lead to heat stroke, which results in organ damage, loss of consciousness, or death.

3.A nurse is attempting to assess a client's pulse in his foot. She palpates the pulse on the anterior aspect of his ankle, below the lower end of the medial malleolus. Which type of pulse is this nurse taking?

• Dorsalis pedis
• Popliteal
• Posterior tibial
• Femoral

ANSWER C: The nurse can palpate the posterior tibial pulse to assess

circulation to the foot and ankle. The posterior tibial pulse is felt by palpating the inner side of the ankle, behind the medial malleolus.

4.Which of the following conditions may cause an increased respiratory rate?

• Stooped posture
• Narcotic analgesics
• Injury to the brain stem
• Anemia

ANSWER D: A client who has anemia has decreased levels of hemoglobin

in the red blood cells. Because hemoglobin is responsible for carrying oxygen molecules to the body's tissues, the client may need to breathe faster to bring in more oxygen to make up for this deficit.

5.Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• Kussmaul respirations
• Cheyne-Stokes respirations
• Biot's respirations
• Cluster breathing

ANSWER A: Kussmaul respirations may be associated with some conditions

such as metabolic acidosis. This type of breathing is actually a form of hyperventilation, resulting in increased buildup of carbon dioxide in the body. Kussmaul respirations are typically rapid, regular, and deep.

6.A nurse is attempting to check a blood pressure on a client when she realizes that the cuff is too wide for the size of his arm. What type of reading might this blood pressure cuff produce?

• A normal result
• An abnormally low reading
• An abnormally high reading

• A low reading, followed by a normal reading

ANSWER B: A blood pressure cuff that is too large for the size of a client's

arm may produce an abnormally low blood pressure result. The cuff should be placed to appropriately fit the size of the client's arm. If a nurse gets an abnormally low blood pressure reading in a client who is not symptomatic, she should check the size of the cuff.

7.Which of the following is a true statement about assessing blood pressure by palpation?

• Only the diastolic blood pressure can be assessed through palpation.
• The palpation technique is most useful for infants and small children.
• Hypertension is a common condition that might need to be assessed

through blood pressure palpation.

• Only the systolic blood pressure can be assessed through palpation.

ANSWER D: Palpating a blood pressure may be necessary in some clients

with pressures that are too low to be heard through a traditional stethoscope.Clients who have fluid volume deficits or decreased cardiac outputs may need blood pressure assessed through palpation. When performing this maneuver, only the systolic blood pressure can be assessed.

8.A nurse is caring for a client who has just come from surgery and is in the recovery room. The client still has an endotracheal tube in place. The nurse deflates the cuff on the tube and pulls it out, at which time the client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?