NCLEX Exam Practice Question of the Week - 6/27/12
Question: The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment findings would cause the nurse concern regarding the development of compartmental syndrome? Select all that apply.
1. Decrease in pulse rate in affected leg
2. Paresthesia distel to area of injury
3. Toes on affected leg cool to touch and edematous
4. Complaints that pins are hurting
5. Complaints of leg pain unrelieved by analgesics or repositioning
6. Client angry and calling loudly to the nurse every 10 minutes
1. Decrease in pulse rate in affected leg
2. Paresthesia distel to area of injury
3. Toes on affected leg cool to touch and edematous
4. Complaints that pins are hurting
5. Complaints of leg pain unrelieved by analgesics or repositioning
6. Client angry and calling loudly to the nurse every 10 minutes
Answer: 2, 3, 5
Rationale: The paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. The decrease in pulse rateis not important; the quality of the pulse is the important observation. The pins usually do not cause undue pain, and frequently, the client is angry regarding the immobility and does not use effective coping measures.
Rationale: The paresthesia, edema, and leg pain unrelieved by analgesics are classic indicators of the development of compartmental syndrome. The decrease in pulse rateis not important; the quality of the pulse is the important observation. The pins usually do not cause undue pain, and frequently, the client is angry regarding the immobility and does not use effective coping measures.
NCLEX Exam Practice Question of the Week - 7/3/12
Question: A nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of:
1. Myxedema
2. Graves’ disease
3. Addison’s disease
4. Cushing’s syndrome
Answer: Answer: 2
Rationale: Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves’ disease. Myxedema indicates hypothyroidism. Cushing’s syndrome and Addison’s disease are disorders related to adrenal function.
NCLEX Exam Practice Question of the Week - 7/11/12
Question: A 32-year-old multigravida client who is at 40 weeks gestation is in early labor. The nurse assesses a fetal heart rate of 90 beats per minute for the last half of the previous three contractions. Which action should the nurse take?
1. Place her in the supine position and prepare an oxytocin infusion.
2. Place her on her left side and administer oxygen.
3. Place her in the knee-chest position and continue to monitor.
4. Place her in the lithotomy position and perform a vaginal examination.
Answer: 2
Rationale: This situation describes late decelerations of the fetal heart rate, which may indicate uteroplacental insufficiency. If this is noted, the nurse may turn the mother onto her left side and administer oxygen to help decrease stress on the fetus. If the client is receiving an oxytocic agent, it should be discontinued at this time. The situation is an emergency and the actions described in answer options 1, 3, and 4 are either incorrect or not effective to treat fetal distress
NCLEX Exam Practice Question of the Week - 7/18/12
Question: A nurse assesses a client admitted to the hospital with rib fractures so as to identify the risk for potential complications. The nurse notes that the client has a history of emphysema.
After the assessment, the nurse ensures that which of the following interventions is documented in the plan of care? Select all that apply.
1. Collect sputum specimens at the hour of sleep.
2. Maintain the client in a position of comfort.
3. Offer medication to suppress the cough as needed.
4. Administer small, frequent meals with plenty of fluids.
5. Have the client cough and breathe deeply 20 minutes after pain medication is given.
6. Administer 4 to 6 liters of oxygen when the client’s pulse oximetry drops below 90%.
Answer: 2, 4, 5
Rationale: If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client’s awakening. Productive cough is more likely to occur after the client has slept. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen (option 6) would halt the hypoxic drive and cause apnea. Options 2, 4, and 5 are appropriate interventions.
NCLEX Exam Practice Question of the Week - 7/25/12
Question: Shortly after an amniotomy, the nurse determines that the fetal heart rate has decreased from 140 to 80 beats per minute. What is the priority nursing action?
1. Inspect the vagina
2. Administer oxygen
3. Notify the practitioner
4. Place in the knee-chest position
Answer: 1
Rationale: Inspection seeks to identify the cause for the decreased fetal heart rate; the cord may have prolapsed. Administering oxygen may be done later, but it is not the priority. The practitioner should be notified after further assessment reveals more information. Placing the client in the knee-chest position is an intervention that can be implemented once it is determined that the umbilical cord is prolapsed; it relieves pressure on the cord, which increases the flow of oxygen and nutrients to the fetus.
NCLEX Exam Practice Question of the Week - 8/1/12
Question: A client is found to be comatose and hypoglycemic with a blood glucose level of 50 mg/dL. What nursing action is implemented first?
1. Infuse 1000 mL of D5W over a 12-hour period
2. Administer 50% glucose intravenously
3. Check the client’s urine for the presence of sugar and acetone
4. Encourage the client to drink orange juice with added sugar.
Correct answer: 2
Rationale: The unconscious, hypoglycemic client needs immediate treatment with 50% intravenous glucose (highly concentrated). 1000 mL of D5W over 12 hours does not provide enough glucose to treat the problem. Trying to give oral fluids to an unconscious client should never be done, because it increases the risk for aspiration. Urine sugar does not need to be evaluated if the serum blood glucose is available.
NCLEX Exam Practice Question of the Week - 8/8/12
Question: Which of the following are characteristics of von Willebrand’s disease? Select all that apply.
1. Easy bruising occurs.
2. Gum bleeding occurs.
3. It is a hereditary bleeding disorder.
4. It is characterized by extremely high creatinine levels.
5. The disorder causes platelets to adhere to damaged endothelium.
6. Treatment and care are similar to that for hemophilia.
Answer: 1, 2, 3, 5, 6
Rationale: von Willebrand’s disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.
NCLEX Exam Practice Question of the Week - 8/15/12
Question: A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client’s neurovascular status?
1. The neurovascular status is normal because of the increased blood flow through the leg.
2. The neurovascular status is moderately impaired, and the surgeon should be called.
3. The neurovascular status is slightly deteriorating and should be monitored for another hour.
4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.
Correct Answer: 1
Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore options 2, 3, and 4 are incorrect interpretations.
NCLEX Exam Practice Question of the Week - 8/22/12
Question: A nurse is performing a physical assessment on a 17-year-old primigravida who is at 30 weeks’ gestation. Which finding would the nurse question as possible mild preeclampsia?
1. Dyspnea
2. Persistent 1+ proteinuria
3. Epigastric discomfort
4. Increase of 15 mm Hg systolic pressure
Correct Answer: 2
Rationale: Persistent trace protein in the urine is most indicative of mild preeclampsia. Dyspnea (1) may normally be experienced in the last trimester of pregnancy. A systolic blood pressure increase of 15 mm Hg (4)is slightly elevated but not as definitive a sign as persistent proteinuria. Epigastric discomfort (3) is a later sign of preeclampsia.
NCLEX Exam Practice Question of the Week - 8/29/12
Question: A client has had a Miller-Abbott tube in place for 24 hours. Which assessment finding indicates that the tube is located in the intestine?
1. The client is nauseous.
2. Bowel sounds are absent.
3. Aspirate from the tube has a pH of 7.
4. The abdominal radiograph report indicates that the end of the tube is above the pylorus.
Correct Answer: 3
Rationale: The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Nausea should subside as decompression is accomplished. Although bowel sounds will be abnormal in the presence of obstruction, the presence or absence of bowel sounds is not associated with the location of the tube. The end of the tube should be located in the intestine (below the pylorus). The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Location of the tube can also be determined by radiographs.
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