NCLEX 801-865 QA 2022

NCLEX #801-865 Q&A 2022 NO.801 A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The

nurse discusses his disease with him and emphasizes the following information:

• He should monitor his sputum, stools, and urine for signs of bleeding.
• His daily diet should include a large amount of fluid.
• He should not be concerned about having to fly on a commuter airplane on a weekly

basis.

• He should not worry about having children because this disease is passed on only by

female carriers. - correct answerAnswer: B Explanation: (A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. (B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. (C) Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. (D) Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this

client should receive genetic counseling prior to having children.NO.802 Hematotympanum and otorrhea are associated with which of the following head injuries?

• Basilar skull fracture
• Subdural hematoma
• Epidural hematoma
• Frontal lobe fracture - correct answerAnswer: A Explanation:

(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.NO.803 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?

• Celery
• Potatoes
• Tomatoes
• Liver - correct answerAnswer: B Explanation:

(A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.NO.804 Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?

• Brain tumor or other space-occupying lesion
• History of mitral valve prolapse
• Surgically repaired herniated lumbar disk 1 / 3

• History of frequent urinary tract infections - correct answerAnswer: A Explanation:

(A) A contraindication for ECT is a space-occupying lesion such as a brain tumor.During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT.In fact, concurrent treatment of infections with ECT is not uncommon.NO.805 A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her

cervix is closed. The client is exhibiting signs of:

• An inevitable abortion
• A threatened abortion
• An incomplete abortion
• A missed abortion - correct answerAnswer: B Explanation:

(A) An inevitable abortion includes the signs of cervical dilation and effacement as well as pain and bleeding. (B) A threatened abortion is a condition in which intrauterine bleeding occurs early in pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled. (C) An incomplete abortion occurs when some portions of the products of conception are expelled from the uterus. (D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.NO.806 A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The

nurse tells the client that the internal mammary artery:

• Takes more time to remove
• Has a greater risk of becoming reoccluded
• Is smaller in diameter
• Has too many valves - correct answerAnswer: A Explanation:

(A) It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it. (B) There is not a greater risk of reocclusion.In fact, it may actually stay patent longer. (C) The internal mammary artery is actually larger in diameter than the saphenous vein. (D) The internal mammary artery does not have too many valves.NO.807 After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred

• times during the 20- minute test. The RN knows that these test results will be

interpreted as:

• A reactive test
• A nonreactive test
• An unsatisfactory test 2 / 3

• A negative test - correct answerAnswer: A Explanation:

(A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date.(D) A negative test is a term used to describe the results of a contraction stress test.NO.808 A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain.When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?

• Call the physician about the problem.
• Irrigate the Foley catheter.
• Change the Foley catheter.
• Administer a prescribed narcotic analgesic. - correct answerAnswer: B Explanation:

(A) The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention.(B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. (C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. (D) Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.NO.809 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds.She is receiving oxytocin.

The nurse's first intervention should be to:

• Check FHT
• Notify the attending physician
• Turn off the IV oxytocin
• Prepare for the delivery because the client is probably in transition - correct

answerAnswer: C Explanation: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do.

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