NCLEX- RN Review Question Assignment 2

NCLEX- RN Review Question Assignment #2 Madison Brinsley1/30/2018 1.The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse

should first:

a.Assess for changes in the vital signs.b.Draw an arterial blood gas.c.Evaluate heart sounds with the client leaning forward.d.Obtain a 12-lead electrocardiogram.Rationale: (a) The nurse should first obtain vital signs as changes in the vital signs will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. (Billings & Hensel, 2017, p. 340) 2.The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor.

The nurse should first:

a.Administer atropine 0.5 mg IV push.b.Auscultate for abnormal heart sounds.c.Prepare for transcutaneous pacing.d.Take the client’s blood pressure.Rationale: (d) The nurse should first assess the client’s tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed.(Billings & Hensel, 2017, p. 341) 3.The nurse is obtaining consent for a bone marrow aspiration. Which actions should the

nurse take? SATA:

a.Witness the client signing the consent form.b.Evaluate that the client understands the procedure.c.Explain the risks of the procedure to the client.d.Verify that the client is signing the consent form of his or her own free will.e.Determine that the client understands postprocedure care.Rationale: (a, b, d, e) The nurse can serve as a witness for consent for the procedures. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form, determines that the client is signing the consent of his or her own free will, and determines that the client understands postprocedure care. The nurse’s role does not include explaining the risks of the procedure; that responsibility belongs to the person who is to perform the procedure, such as the HCP. (Billings & Hensel, 2017, p. 400) 4.Which mental status change may occur when a client with pneumonia is first experiencing hypoxia? This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00

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a.Coma b.Apathy c.Irritability d.Depression Rationale: (C) Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia. (Billings & Hensel, 2017, p. 429) 5.A nurse is assessing a client with chronic emphysema. Which finding requires immediate intervention?a.Using pursed-lip breathing and prolonged expiration b.Circumoral cyanosis c.Crackles auscultated posteriorly halfway up the left lung d.Appearance of a “barrel chest” Rationale: (c) Crackles auscultated in the lung field indicate excessive fluid, a problem that requires immediate intervention. Pursed-lip breathing and a prolonged expiratory phase, circumoral cyanosis, and increased anterior posterior diameter of the chest are not unusual findings in emphysema patients. (Billings & Hensel, 2017, p. 431) This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00

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References Billings, D. & Hensel, D., (2017). Lippincott q&a review for NCLEX-RN (12 th ed.).Philadelphia, PA: LWW. This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00

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NCLEX – RN Review Question Assignment Name Madison McDonald Date 1/30/18 1.A client has an advance directive. How do you explain this to the client's? family?A.Say that the advance directive is a guidance that can be used in the client's care B.Say that the advance directive is the same as the patients will C.Say that the advance directive is a legal document allowing the client to express his or her wishes in certain death situations D.Say that the advance directive no longer applies if the patient is suicidal Rationale: (C) The advance directive is a legally-binding document that allows the client to express his or her wishes in certain health situations. It is not a guideline for care nor is it the same as the person's will. The advance directive applies regardless of the patient's mental condition unless it is legally changed by the client himself. (Hassan, 2015, p. 2)

2.Which of the following is part of the advance directive? Select all that apply.

• The durable power of attorney is named
• A list of patients wishes in certain medical situation
• A list of the client's beneficiaries
• Organ donation wishes
• Listing of client medication allergies

Rationale: (A. B. D.) The advance directive usually contains a list of the client's wishes in certain medical situations as well as naming the durable power of attorney when it comes to making medical decisions. Organ donation wishes can be included in the advance directives but, as it pertains to healthcare it does not list the client's beneficiaries nor are allergies included (Hassan, 2015, p 3)

3.When assessing the client's abdomen, what is the first thing a nurse will do?

• Auscultation
• Inspection
• Percussion
• Palpation

Rationale: (B) The first step in assessing the abdomen is inspection, followed in order by auscultation, percussion and palpitation (Hassen, 2015, p.34)

4.When exanimating a 1year old's ear with an otoscope, the nurse does what to visualize the tympanic membrane?

• Pulls the ear back and down
• Pulls the ear back and up
• Pulls ear forward
• Does not pull on the ear at all This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00

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