Nclex Questions - Nclex Questions Stephanie Smith Chapter 26 – ...

ATI Adult Medical-Surgical Nursing Nclex Questions Stephanie Smith Chapter 26 – Respiratory Failure

• A nurse in an emergency department is assessing a client who was in a MVC. Findings

include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 (101.4 ), and SaO2 92% on room

℃ ℉

air. Which of the following actions should the nurse take first?A.Obtain a chest x-ray.B.Prepare for chest tube insertion.C.Administer oxygen via a high-flow mask.D.Initiate IV access.Rationale: C- According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to provide the client oxygen to restore optimal breathing.

• A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a

client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?A.“This medication is given to treat infection.” B.“This medication is given to facilitate ventilation.” C.“This medication is given to decrease inflammation.” D.“This medication is given to reduce anxiety.” Rationale: B- Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.

• A nurse is reviewing the health records of five clients. Which of the following clients are at

risk for developing acute respiratory distress syndrome? (Select all that apply.) A.A client who experienced a near-drowning incident B.A client following a coronary artery bypass graft surgery.C.A client who has a hemoglobin of 15.1 mg/Dl D.A client who has dysphagia E.A client who experienced a drug overdose Rationale: A, B, D, E- A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. A client who experienced a drug overdose is at risk for developing ARDS due to damage to the central nervous system.

• A nurse is planning care for a client who has severe acute respiratory distress system (SARS).

Which of the following actions should be included in the plan of care for the client? (Select all that apply.) .

A.Administer antibiotics.B.Provide supplemental oxygen.C.Administer antiviral medications.D.Administer of bronchodilators.E.Maintain ventilatory support.Rationale: B, D, E- Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered given to treat severe hypoxemia. Administering of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client’s airway. Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.

• A nurse is caring for a client who is receiving vecuronium for acute respiratory distress

syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A.Fentanyl B.Furosemide C.Midazolam D.Dexamethasone Rationale: A, C- Fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. Midazolam is a sedative medication used to treat clients with ARDS when a neuromuscular blocking agent such as vecuronium is administered.Chapter 27 – Cardiovascular Diagnostic and Therapeutic Procedures

• A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed

for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching?A.“Air should be instilled into the monitoring system prior to the procedure.” B.“The client should be positioned on the left side during the procedure.” C.“The transducer should be level with the second intercostal space after the line is placed.” D.“A chest x-ray is needed to verify placement after the procedure?” Rationale: D- The nurse should ensure that a chest x-ray is obtained to confirm proper placement of the lines following placement.

• A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a

CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following finding should the nurse expect?A.Poor skin turgor B.Bilateral crackles in the lungs C.Jugular vein distension D.Dry mucous membranes E.Hepatomegaly

Rationale: B, C, E- The nurse should expect the client to have bilateral crackles in the lungs for an increased CVP and PAWP. The nurse should expect the client to have jugular vein distention for an increased CVP and PAWP. The nurse should expect the client to have hepatomegaly for an increased CVP and PAWP.

• A nurse is teaching a client who is scheduled for an angiography. Which of the following

statements should the nurse include in the teaching? (Select all that apply.) A.“You should have nothing to eat or drink for 4 hours prior to the procedure.” B.“You will be given general anesthesia during the procedure.” C.“You should not have this procedure done if you are allergic to eggs.” D.“You will need to keep your affected leg straight following the procedure.” Rationale: D- The nurse should instruct the client of the need to remain on bed rest in the supine position with the affected leg straight for a prescribed amount of time. This positioning decreases the client’s risk for bleeding and hematoma formation at the catheter insertion site.

• A nurse at a provider’s office is reviewing the laboratory test results for a group of clients.

The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A.Cholesterol (total) 245 mg/Dl B.HDL 90 mg/dL C.LDL 140 mg/Dl D.Triglycerides 125 mg/Dl E.Troponin I 0.02 ng/mL Rationale: A, C- A client who has a total cholesterol level greater than 200 mg/Dl is at increased risk for heart disease. A client who has an LDL greater than 130 mg/Dl is at increased risk for heart disease.

• A nurse is planning care for a client who has a PICC line in the right arm. Which of the

following interventions should the nurse include in the plan of care? (Select all that apply.) A.Use a 10 mL syringe to flush the PICC line.B.Apply gentle force if resistance is met during injection.C.Cleanse ports with alcohol for 15 seconds prior to use.D.Maintain a transport dressing over the insertion sit.E.Flush with 10 mL heparin before and after medication administration.Rationale: A, C, D- The nurse should use a 10 mL syringe to flush the PICC line to avoid excess pressure that could cause catheter fracture/rupture. The nurse should cleanse insertion ports with alcohol for 15 seconds and allow it to air dry prior to use. This action decreases the risk for bacterial contamination. The nurse should maintain a transparent dressing over the insertion site to decrease the risk for infection and allow for visualization. The nurse should plan to change the dressing at least every 7 days and when wet, loose, or soiled.Chapter 28 – Electrocardiography and Dysrhythmia Monitoring

• A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of

the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A.A client who has metabolic alkalosis B.A client who has a serum potassium level of 4.3 mEq/L C.A client who has an SaO2 of 96% D.A client who had COPD E.A client who underwent stent placement in a coronary artery Rationale: A, D, E- A client who has an acid-base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. A client who has lung disease, such as COPD, is at risk for a dysrhythmia. A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia.

• A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and

is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? (Review the data below for additional client information)

MAR:

Ferrous Sulfate 200 mg PO 0800 and 2000 Diazepam 2 mg PO 0800 and 2000 Isosorbide 2.5 mg PO 4 times a day AC and HS

VITAL SIGNS:

0800 – T 99.5F

Blood pressure 142/86 mm Hg Heart rate 88/min and irregular Respirations 20/min

HISTORY & PHYSICAL:

Bariatric surgery 10 years ago Dyspnea with exertion for 3 years Atrial fibrillation began 3 years ago Client reports taking the following medications for the past 6 weeks: Iron supplement, multivitamin, antilipemic, and nitroglycerin A.Respiratory history B.Vital signs C.Medication history D.Medications to be administered Rationale: C- A client who is to undergo cardioversion needs to be on anticoagulant therapy for 4-6 weeks prior to the procedure.

• A nurse is caring for a client who experienced defibrillation. Which of the following should

be included in the documentation of this procedure? (Select all that apply.) A.Follow-up ECG B.Energy settings used C.IV fluid intake D.Urinary output E.Skin condition under electrodes