NCLEX Exam Practice Question of the Week - 09/21/11
Question: A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 100 beats/min. The nurse determines that the client is experiencing which of the following dysrhythmias?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions
Answer: 3
Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular.
Test-taking Strategy:Focus on the data in the question. Eliminate option 1 first because there are no P waves. Premature ventricular contractions are isolated ectopic beats superimposed on an underlying rhythm, so option 4 is eliminated next. Recalling that there are no true QRS complexes with ventricular fibrillation will direct you to option 3 from the remaining options. Review the characteristics of ventricular tachycardia if you are unfamiliar with it.
Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular.
Test-taking Strategy:Focus on the data in the question. Eliminate option 1 first because there are no P waves. Premature ventricular contractions are isolated ectopic beats superimposed on an underlying rhythm, so option 4 is eliminated next. Recalling that there are no true QRS complexes with ventricular fibrillation will direct you to option 3 from the remaining options. Review the characteristics of ventricular tachycardia if you are unfamiliar with it.
NCLEX Exam Practice Question of the Week - 09/28/11
Question: During a well-woman physical examination, a young woman is diagnosed with a primary genital herpes lesion. When completing the client’s history, the nurse would anticipate the client to report:
1. Anuria
2. Pruritus
3. Leukorrhea
4. Dyspareunia
1. Anuria
2. Pruritus
3. Leukorrhea
4. Dyspareunia
Answer:4
Rationale: The client usually seeks treatment for a variety of symptoms, including dyspareunia (painful intercourse) due to the pain from the ulcerations caused by HSV-2. Anuria would be a complication of renal failure, as would pruritus. Leukorrhea is a thick, whitish, vaginal discharge that is common during pregnancy and at other times during a woman’s reproductive years.
Rationale: The client usually seeks treatment for a variety of symptoms, including dyspareunia (painful intercourse) due to the pain from the ulcerations caused by HSV-2. Anuria would be a complication of renal failure, as would pruritus. Leukorrhea is a thick, whitish, vaginal discharge that is common during pregnancy and at other times during a woman’s reproductive years.
NCLEX Exam Practice Question of the Week - 10/5/11
Question: A 38-year-old gravida VII, para VI woman has just delivered an 8 pound, 5 ounce newborn. What complication should the nurse monitor for during the fourth stage of labor?
1. Uterine shock
2. Uterine atony
3. Uterine involution
4. Cardiogenic shock
1. Uterine shock
2. Uterine atony
3. Uterine involution
4. Cardiogenic shock
Rationale: Uterine atony is the most common cause of postpartal hemorrhage. To control bleeding, the muscle fiber must contract and stay tightly contracted or profuse bleeding will occur. This emergency occurs most commonly in multiparas, because previous deliveries weaken muscle fibers. Uterine shock (1) is an incorrect term. Uterine involution (3) is the normal process of return of the uterus to a nonpregnant state after birth. Cardiogenic shock (4) is not a common complication unless there is another underlying cardiac issue.
NCLEX Exam Practice Question of the Week - 10/12/11
Question: Nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
1. 5 minutes
2. 15 minutes
3. 40 minutes
4. 45 minutes
1. 5 minutes
2. 15 minutes
3. 40 minutes
4. 45 minutes
Answer: 2
Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore options 1, 3, and 4 are incorrect time frames.
Test-Taking Strategy: Use knowledge regarding blood transfusion procedures to answer this question. Remember that the client must be monitored directly for the first 15 minutes of the transfusion. Review the nursing responsibilities involved in beginning a blood transfusion if you had difficulty with this question.
Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore options 1, 3, and 4 are incorrect time frames.
Test-Taking Strategy: Use knowledge regarding blood transfusion procedures to answer this question. Remember that the client must be monitored directly for the first 15 minutes of the transfusion. Review the nursing responsibilities involved in beginning a blood transfusion if you had difficulty with this question.
NCLEX Exam Practice Question of the Week - 10/19/11
Question: To prevent complications of immobility, what would be the most effective activities to implement for a client on the first postoperative day after a colon resection?
1. Turn, cough, and deep-breathe every 30 minutes around the clock
2. Get the client out of bed and ambulate to a bedside chair
3. Provide passive range of motion three times a day
4. Immobility is not a concern on the first postoperative day
1. Turn, cough, and deep-breathe every 30 minutes around the clock
2. Get the client out of bed and ambulate to a bedside chair
3. Provide passive range of motion three times a day
4. Immobility is not a concern on the first postoperative day
Answer: 2
Rationale: Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing. Passive range of motion maintains joint mobility but is not as effective as weight bearing to prevent venous stasis and the complications of immobility. Turning and coughing every 30 minutes around the clock is too often-it would disrupt effective rest and sleep. Every 2 hours is the standard. Prevention of complications of immobility begins when the client becomes immobilized.
Rationale: Weight bearing increases the vascular tone and decreases venous stasis, thereby preventing thrombi from developing; the increase in activity increases respiratory expansion and quality of breathing. Passive range of motion maintains joint mobility but is not as effective as weight bearing to prevent venous stasis and the complications of immobility. Turning and coughing every 30 minutes around the clock is too often-it would disrupt effective rest and sleep. Every 2 hours is the standard. Prevention of complications of immobility begins when the client becomes immobilized.
NCLEX Exam Practice Question of the Week - 10/26/11
Question: On the first postoperative day the nurse assesses a client’s colostomy stoma and notes that it is moist and dark pink with no obvious drainage. Which action should the nurse consider taking?
1. Document the normal findings.
2. Consult the enterostomal therapist.
3. Irrigate the ostomy with normal saline.
4. Palpate the abdomen around the stoma.
1. Document the normal findings.
2. Consult the enterostomal therapist.
3. Irrigate the ostomy with normal saline.
4. Palpate the abdomen around the stoma.
Answer: 1
Rationale: A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day has a normal appearance. These findings should be documented in the client’s medical record. The items in the other answer options (2, 3, 4) are not necessary because the assessment of the colostomy stoma is normal.
Rationale: A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day has a normal appearance. These findings should be documented in the client’s medical record. The items in the other answer options (2, 3, 4) are not necessary because the assessment of the colostomy stoma is normal.
NCLEX Exam Practice Question of the Week - 11/2/11
Question: A multipara is admitted to the birthing room in active labor. Her vital signs are temperature, 98° F; pulse, 70 beats per minute; respirations, 18 per minute; and blood pressure, 126/76. A vaginal examination reveals a cervix that is 90% effaced and 7cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?
1. Naloxone (Narcan)
2. Lorazepam (Ativan)
3. Meperidine (Demerol)
4. Promethazine (Phenergan)
1. Naloxone (Narcan)
2. Lorazepam (Ativan)
3. Meperidine (Demerol)
4. Promethazine (Phenergan)
Answer: 3
Rationale: Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone (Narcan) is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam (Ativan) is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine (Phenergan) is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.
Rationale: Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone (Narcan) is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam (Ativan) is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine (Phenergan) is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.
NCLEX Exam Practice Question of the Week - 11/9/11
Question: An infant has just returned to the nursing unit after a surgical repair of a cleft lip on the right side. The nurse places the infant in which best position at this time?
1. Prone position
2. On the stomach
3. Left lateral position
4. Right lateral position
1. Prone position
2. On the stomach
3. Left lateral position
4. Right lateral position
Answer: 3
Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, a nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.
Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, a nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.
NCLEX Exam Practice Question of the Week - 11/16/11
Question: A nurse is teaching a community group about a low-fat, low-sodium diet. Which menu choices would be appropriate? (Select all that apply.)
1. Fresh fruit platter with a glass of skim milk
2. Tuna salad with mayonnaise dressing and saltine crackers
3.Cheeseburger with lettuce and tomato, and french fries
4. Ham and cheese sandwich on white bread, and chicken soup
5. Baked chicken without the skin, rice, and steamed asparagus
1. Fresh fruit platter with a glass of skim milk
2. Tuna salad with mayonnaise dressing and saltine crackers
3.Cheeseburger with lettuce and tomato, and french fries
4. Ham and cheese sandwich on white bread, and chicken soup
5. Baked chicken without the skin, rice, and steamed asparagus
Answer: 1 & 5
Rationale: Rationale: Baked chicken without the skin, rice, and fresh asparagus are lowest in fat and salt content, as are fruit and skim milk. Mayonnaise and saltine crackers (2), a cheeseburger with french fries (3), and a ham and cheese sandwich with chicken soup (4), do not meet low-sodium, low-fat requirements. NCLEX Exam Practice Question of the Week - 11/23/11
Question: A practitioner plans to have a client with the diagnosis of bipolar disorder continue taking lithium after discharge. The nurse identifies that the teaching about the medication plan is understood when the client states “I know that this medication:
1. should be stopped if illness is suspected.”
2. may need to be taken for the rest of my life.”
3. causes no serious side effects when taken correctly.”
4. will require me to increase the dosage at the beginning of a manic episode.”
1. should be stopped if illness is suspected.”
2. may need to be taken for the rest of my life.”
3. causes no serious side effects when taken correctly.”
4. will require me to increase the dosage at the beginning of a manic episode.”
Answer: 2
Rationale: For clients with bipolar disorders, it has been shown that long-term lithium therapy flattens the highs of the euphoric episodes and minimizes the lows of the depressed episodes. The practitioner should be notified before medication is stopped. The therapeutic level and the toxic level are very close, and serious side effects can occur. Clients should never adjust their own dosage of medication.
Rationale: For clients with bipolar disorders, it has been shown that long-term lithium therapy flattens the highs of the euphoric episodes and minimizes the lows of the depressed episodes. The practitioner should be notified before medication is stopped. The therapeutic level and the toxic level are very close, and serious side effects can occur. Clients should never adjust their own dosage of medication.
No comments:
Post a Comment