Final Exam NCLEX Questions

Final Exam NCLEX Questions Leave the first rating Students also studied Terms in this set (76) Science MedicineNursing Save emergency nursing of the adult 47 terms cmmata2211Preview Adult Health final (NCLEX questions...103 terms miggyt1996Preview

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jaffarisPreview Core C 49 terms ali_ A 38-year-old female is brought to the Emergency Department with complaints of her "heart beating out of her chest". She is diaphoretic, tachypneic and her BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva maneuvers and three doses of Adenosine have not been successful. The nurse should

immediately:

a.) prepare the patient for synchronized cardioversion.b.) give Epinephrine 1 mg IV and repeat in 3 minutes.c.) give Adenosine 6 mg IV per protocol.d.) perform unilateral carotid massage.a.) prepare the patient for synchronized cardioversion.A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority?

• A complete history with emphasis on preceding

events.

• An electrocardiogram.
• Careful assessment of vital signs.
• Chest exam with auscultation.

Answer: C

The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings?

• Complaints of pain during repositioning.
• Scant bloody discharge on the surgical dressing.
• Complaints of pain following physical therapy.
• Temperature of 101.8 F (38.7 C).

Answer: D

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority?

• A patient with low-grade fever, headache, and

myalgias for the past 72 hours.

• A patient who is unable to bear weight on the left foot,

with swelling and bruising following a running accident.

• A patient with abdominal and chest pain following a

large, spicy meal.

• A child with a one-inch bleeding laceration on the chin

but otherwise well after falling while jumping on his bed.

Answer: C

Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non- urgent.A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?

• pH 7.52, PCO2 54 mm Hg.
• pH 7.42, PCO2 40 mm Hg.
• pH 7.25, PCO2 25 mm Hg.
• pH 7.38, PCO2 36 mm Hg.

Answer: A

A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2.A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock?a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Septic a.) Hypovolemic

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first?a.) Antibiotics to treat the underlying infection.b.) Corticosteroids to reduce inflammation.c.) IV fluids to increase intravascular volume.d.) Vasopressors to increase blood pressure.c.) IV fluids to increase intravascular volume.

Rationale:

Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage Which of the following assessment findings is an early indication of hypovolemic shock?a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension c.) Tachycardia

Rationale:

Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize?a.) Intensity of peripheral pulses and body temperature.b.) Peripheral pulses and heart rate (HR).c.) Metabolic alkalosis and oxygen saturation.d.) Cardiac output (CO) and blood pressure (BP).d.) Cardiac output (CO) and blood pressure (BP).A client is progressing into the third stage of shock. The

nurse will expect this client to demonstrate:

Choose all that apply:

a.) Intractable circulatory failure.b.) Neuroendocrine responses.c.) Demonstrating MODS.d.) Buildup of metabolic wastes.e.) Profound hypotension.f.) Increase in lactic acidosis.c.) Demonstrating MODS.d.) Buildup of metabolic wastes.A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this

client:

Select all that apply:

a.) Rapid shallow respirations.b.) Severe hypotension.c.) Mental status changes.d.) Elevated temperature.e.) Lactic acidosis.f.) Oliguria.a.) Rapid shallow respirations.d.) Elevated temperature.

Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention

includes:

a.) Monitoring for fluid overload.b.) Monitoring for cardiac dysrhythmias.c.) Monitoring respiratory status.d.) Monitoring for hypotension.b.) Monitoring for cardiac dysrhythmias.

Rationale:

Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output.c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.

Rationale: The release of aldosterone and ADH lead to the decrease in urine

output by increasing the reabsorption of sodium and water in the renal tubules.SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin.b.) shortness of breath.c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.c.) heart rate of 48 beats/min

Rationale: The normal sympathetic response to shock/hypotension is an increase

in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting

tight." The first action the nurse should take is:

• assess the child's airway and breathing
• call 911 and request an ambulance
• administer subcutaneous epinephrine
• remove the stinger from the foot

a.) access the child's airway and breathing

Rationale:

The situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC.