This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial

PRIMEXAM

NCLEX RN Comprehensive 2022

Question: A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triagenursesendback to beseen first?

• A 2-month-old infant with ahistory of rolling off the bed and has bulging fontanellewith crying

• A teenager who got a singed beard while camping

• An elderly client with complaintsof frequent liquid browncolored stools

• A middle-aged client with intermittent pain behind the right scapula

{{{Correct Ans-B. A teenager whogot a singed beard while camping

This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs has no nerve fibers so the client will not be aware of swelling.)

Question: While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmentalneeds?

• "I want to protect my child from any falls."

• "I will set limits on exploring the house."

• "I understand the need to use those new skills."

• "I intend to keep control overourchild."

{{{Correct Ans-C. "I understandthe need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motorskillsto explore the environment and develop autonomy.)

Question: The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding

tube. The most important actionof the nurse is:

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PRIMEXAM

Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The

• Verify correct placement of the tube

• Check that the feedingsolutionmatches the dietaryorder

• Aspirate abdominal contentsto determine the amount of last feeding remaining in stomach

• Ensure that feeding solution is at room temperature

{{{Correct Ans-A.Verify correct placement of the tube

Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested forbilirubinto confirm it isplaced in thestomach.)

Question: The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV.Which of the following EKGpatterns indicates to the nurse that the infusions shouldbe discontinued?

• Narrowed QRS complex

• Shortened "PR" interval

• Tall peaked "T" waves

• Prominent "U" waves

{{{Correct Ans-C. Tall peaked"T" waves

A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing themedication.)

Question: A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert thestaff to pay more attentionto the functionof which area of the body?

• All striated muscles

• The cerebellum

• The kidneys

• The leg bones

definitive way to ascertain the position of the nasogastric tube is through visualization by an x -ray. 2 / 4

PRIMEXAM

{{{Correct Ans-A. All striated muscles

Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. Symptoms of rhabdomyosarcoma include if the cancer is in the head or neck area: sudden bulging or swelling of the eyes, conjunctival chemosis, and headache. It can also affect the urinary or reproductive system. Its common site of metastasis is the lung.)

Question: The nurse anticipates that for a family who practices Chinese medicine the priority goal would

be to:

• Achieve harmony

• Maintain a balance of energy

• Respect life

• Restore yin and yang

{{{Correct Ans-D. Restore yinand yang

For followers of Chinese medicine, health is maintained through the balance between the forces of yin and yang. Traditional Chinese medicine is a medical system that began being developed in China about 5000 years ago, which makes it theoldestcontinuous medical system onthe planet.) Question: During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complainsof periodicdizzyspells. Thenurse instructs theclient to:

• Increase fluids that are high in protein

• Restrict fluids

• Force fluids and reassessblood pressure

• Limit fluids to non-caffeinebeverages

{{{Correct Ans-C. Force fluids and reassess bloodpressure

Orthostatic hypotension, a decrease in systolic blood pressure of more than 15 mmHg, and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicate volume depletion, 3 / 4

PRIMEXAM

inadequate vasoconstrictormechanisms, and autonomicinsufficiency.)

Question: The nurse prepares the client for the insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:

• Stroke volume

• Cardiac output

• Venous pressure

• Left ventricular functioning

{{{Correct Ans-D. Left ventricular functioning

The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheterballoonisinflated.)

Question: A nurse enters a client's room to discover that the client has no pulse or respirations. After

calling forhelp, thefirst action thenurseshould takeis:

• Start a peripheral IV

• Initiate high-quality chest compressions

• Establish an airway

• Obtain the crash cart

{{{Correct Ans-B. Initiatehigh-quality chest compressions

As per new guidelines, the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults, children, and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and othervital organs until more definitivemedical treatment can restore a normal heart rhythm.)

Question: A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

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