NCLEX Questions airway, breathing, circulation

NCLEX Questions/ airway, breathing, & circulation questions Leave the first rating Students also studied Terms in this set (20) Science MedicineNursing Save Prioritization NCLEX questions 28 terms madisoncastello Preview

Vital Signs: Key Measurements and ...

21 terms tichina_jamesPreview NCLEX Questions 20 terms maria_schroeder Preview Nclex Q 32 terms kar a, b, d

a. Auscultating lung sounds: This is important to assess

the quality of breath sounds, presence of abnormal sounds such as crackles or wheezes, and overall lung function.

b. Obtaining the client's temperature: Measuring the

client's temperature helps assess for the presence of fever, which is a common symptom associated with respiratory infections.

d. Obtaining information about the client's respirations:

Assessing the client's respiratory rate, depth, and effort is important to determine if there are any abnormalities or signs of respiratory distress.The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select All That Apply.

• auscultating lung sounds
• obtaining the client's temperature
• assessing the strength of peripheral pulses
• obtaining information about the clients respirations
• performing a musculoskeletal and neurological examination
• asking the client about a family history of any illness or disease

a

rationale: ABC's (airway, breathing, circulation)

The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action on arrival of the client?

• assess the potency of the airway
• check tubes or drains for patency
• check the dressing to assess for bleeding
• assess the vital signs to compare with preoperative measurement

b

rationale: fever increases RR in attempts to blow off the

heat; ICP cause Th (slow down breathing) The nurse understands that which statement is correct regarding respiratory rates?

• infants have a lower respiratory rate than adults
• healthy adults breathe between 12 and 20 times a minute
• a compensatory response to a fever is to breathe at a slower rate
• an increase in intracranial pressure results in an increased rate

b

rationale: you need to compare and check for symmetry

when assessing a patient.While auscultating a patient's lungs, the nurse notes diminished breath sounds at the base of the right lung. What action should the nurse take next?

• refer the patient for a chest x-ray
• listen to the base of the patient's left lung
• notify the patient's primary care provider
• palpate the patient's lung fields bilaterally

b

Rationale: The normal respiratory rate in a 12-month-old

infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56mm Hg. The nurse would document the

findings.TTS: Focus on the data in the question and note

the strategic words most appropriate. Recalling the normal vital signs of an infant and noting that the respiratory rate identified in the question is within the normal range will direct you to the correct option The nurse assess the vital signs of a 12-month old infant with respiratory infection and notes the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?

• administer oxygen
• document the finding
• notify the health care provider
• reassess the respiratory rate in 15 minutes

bThe nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being appropriate method, indicates the need for further teaching?

• taking a rectal temperature for a client who has undergone nasal surgery
• taking an oral temperature for a client with a cough and nasal congestion
• taking an axillary temperature for a client who has just consumed hot coffee
• taking a temporal temperature on the neck behind the ear for a client who is

diaphoretic dA staff nurse is precasting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates a need for further teaching regarding pain management?

• "I will be sure to ask my client what his pain level is on a scale of 0 to 10"
• "I know that I should follow up after giving medication to make sure it is

effective."

• "I know that pain in the older client might manifest as sleep disturbances or

depression."

• "I will be sure to cue in to any indication that the client may be exaggerating

their pain.

dA client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? stopped here

• discard them in the unit trash
• return them to the hospital pharmacy
• save them for return to the manufacturer
• prepare to send them to the laboratory for culture

b

Rationale: The anterior fontanel is diamond-shaped and

located on the top of the head. The fontanel should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees

TTS: Note the strategic words most appropriate, and the

words soft and flat. This should provide you with the clue that this is a normal finding. A bulging or tense fontanel may result from crying or increased intracranial pressure the nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

• increase oral fluids
• document the finding
• notify the health care provider (HCP)
• elevate the head of bed to 90 degrees

cThe nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse?

• a man who has moderate hypertension
• a man who has newly diagnosed cataracts
• a woman who has advanced Parkinson's disease
• a woman who has early diagnosed Lyme disease

b Drowsiness in a client may indicate a potential change in their condition or a need for intervention. Before taking any further actions, the nurse should attempt to wake up the client to assess their level of consciousness, response, and ability to follow commands. The nurse should gently stimulate the client by calling their name, lightly shaking their shoulder, or providing other appropriate means to arouse them.The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2 F (36.2 C) orally, pulse 52 beats per minute, blood pressure 101/58 mmHg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

• document the findings
• attempt to arouse the client
• contact the health care provider immediately
• check the medication administration history on the PCA pump

bThe nurse is testing extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

• test the corneal reflexes
• test the 6 cardinal positions of gaze
• test visual acuity, using a Snellen eye chart
• test sensory function by asking the client to close the eyes and then lightly

touching the forehead, cheeks, and chin

aThe nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?

• reflecting a cultural value
• an acceptance of treatment
• client agreement to required procedures
• client understanding of the preoperative procedures

bWhen communicating with a client who speaks a different language, which best practice should the nurse implement?

• speak loudly and slowly
• arrange for an interpreter to translate
• speak to the client and family together
• stand close to the client and speak loudly

cWhich is the best nursing intervention regarding complementary and alternative medicine?

• advising the client about "good" versus "bad" therapies
• discouraging the client from using any alternative therapies
• educating the client about therapies that he or she is interested in using
• identifying herbal remedies that the client should request from the health care

provider cAn antihypertensive medication has been prescribed for a client. The client tells the nurse that he would like to take an herbal supplement to help lower his blood pressure. The nurse should take which action?

• advise the client to read labels of herbal therapies closely
• tell the client that herbal substances are not safe and should never be used
• encourage the client to discuss the use of an herbal substance with the health

care provider

• tell the client that if he takes the herbal substance, he will need to have his

blood pressure checked frequently 28.13 BMI (overweight) 190 x 705/ 4761=

133,950/4761= 28.13

Upon admission, a client's weight is 190 lbs and his height is 5 feet 9 inches. What is the BMI classification for this client?A, D

Rationale: Peristalsis is not visible. There should be no

bulges. Normal contour of abdomen can be slightly sunken, protruding or flat dependent on client’s body structure and veins may appear faint, but not enlarged.Which of the following are abnormal findings in an abdominal assessment? Select all that apply.

• Visible peristalsis in all four quadrants
• Skin paler than other parts of the body
• Striae or stretch marks across the abdomen
• Bulges observed during inspection
• Enlarged veins noted in upper right quadrant