NGN/NCLEX Prep Questions/Rationales

NGN/NCLEX Prep Questions/Rationales 4.3 (4 reviews) Students also studied Terms in this set (24) George Brown College Nursing Save Nursing 155 Practice Complex Next-...10 terms Jheanelle_Goodwin Preview NCLEX NGN Pre-Test Questions 73 terms CamadarPreview 75 Free NCLEX Questions - c/o Brilli...75 terms carey47Preview NCLEX Teacher Tuto The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus.The nurse should suspect Your Answer: hypokalemiaCorrect Answer: hypokalemia because of the Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves and occasional U waves

Rationale:Cardiac changes in hypokalemia include impaired repolarization,

resulting in a flattening of the T wave and eventually the emergence of a U wave.Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options provided.

The nurse should: (Select 1 option)

✓Ask the client if the chain and medal can be removed during the procedure.

Because: (Select 1 option)

✓The chain and medal may have cultural significance.

Rationale:Before certain diagnostic procedures, it is typical to have a client

remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the item can be either removed temporarily or placed on another part of the body during the procedure if appropriate.

While preparing a client for surgery scheduled in 1 hour,

the client states to the nurse: "I have changed my mind. I

don't want this surgery." Click to highlight the correct answer from the options provided.

The nurse should: (Select 1 option)

Cancel the surgery.Contact the surgeon.✓Discuss the client's concerns.Call the identified support person.

Because: (Select 1 option)

Client consent is required prior to any procedure.✓Further questions or concerns should be determined and addressed.Ethical considerations are important for a client undergoing surgery.The nursing scope of practice places limitations on how the nurse can respond.Rationale:If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs.

The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?For each action, click to specify

whether the action would be:

Indicated: an action that the nurse should take to resolve

the problem

Non-essential: an action that the nurse could take without

harming the client, but the action would not be likely to address the problem

Contraindicated: an action that could harm the client and

should not be taken Collect identifying patient information Contraindicated Note the mental status of the client Non-essential Note primary and secondary diagnoses of clients affected Indicated Note the type of IV catheter used Indicated Note the type of IV site dressings being used Indicated Note the medication types being infused Non-essential Note frequency of assessments of IV sites Indicated Note the expected duration of the IV site Non-essential Note care procedures to the IV site Indicated Note frequency of changing IV sites Indicated

Rationale:Quality improvement, also known as performance improvement,

focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used. Collecting identifying client information is contraindicated because of confidentiality and is unnecessary in this quality improvement effort. Noting the mental status of the clients can be done but is not likely to address the problem. Noting the types of medications being infused can also be done, but will not address the problem of IV site infection. Although it is helpful to know the expected duration of the IV site, this information does not change infection control practices in managing the IV site and is therefore considered a non-essential action.

The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the correct missing information by choosing from the lists of options in the drop-down menus.The test result is Your Answer: Abnormal Correct Answer: Abnormal because Your Answer: The time for color to return is prolonge Correct Answer: The time for color to return is prolonged

Rationale:Failure to determine the presence of adequate collateral circulation

before drawing an arterial blood gas specimen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture.Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to

• seconds, the ulnar artery is insufficient, indicating that the radial artery should

not be used for obtaining a blood specimen. Another site needs to be selected for the arterial puncture, and the primary health care provider needs to be notified of the finding.The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client's vital signs. Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again.

30 min ago:

BP= 142/78

HR= 98

RR= 14

Temp= 37.2 C O2 sat= 95% 3L NC

Current:

BP= 95/54 (F/U correct) HR= 118 (F/U correct)

RR= 18

Temp= 36.8 C O2 sat= 91% 3L NC (F/U correct)

Rationale:Some of the client's vital signs are showing a significant change,

particularly the blood pressure, heart rate, and oxygen saturation levels. The nurse should first compare the current vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about how much of a change has occurred in these parameters. The nurse should quickly consider the following when determining the next action: (1) What is the client's condition? Is the client responding to stimuli? (2) Does the oxygen saturation increase if the client deep breathes? (3) Is the equipment working properly? (4) Is the correct equipment being used? (5) Is there a condition or procedure in the client's history that can be attributed to this change? (6) Are there environmental factors that could influence the change in the client's vital signs? (7) Does this change in the client necessitate contacting the surgeon? Given the significant changes from the baseline vital signs, and after checking the client and equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding such as drainage on the dressing, bloody output in a surgical drain, or swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status.