Nursing Nclex Practice Questions Test Bank

SubmissionDetails SubmissionDate:1/17/2017 SubmissionTime:9:55PM PointsAwarded:115 PointsMissed:10 NumberofAttemptsAllowed:1 NotScored:0 Percentage:92%1. Questions1. 1. ID:9476967734Anursenotesthatthesiteofaclientsperipheralintravenous(IV)catheterisreddened,warm,painful,andslightlyedematousneartheinsertionpointofthecatheter.Onthebasisofthisassessment,thenurseshouldtakewhichaction first?A. RemovetheIVcatheter CorrectB. SlowtherateofinfusionC. NotifythehealthcareproviderD. CheckforloosecatheterconnectionsRationale: Phlebitisisaninflammatoryprocessinthevein.PhlebitisatanIVsitemaybeindicatedbyclientdiscomfortatthesiteorbyredness,warmth,andswellingintheareaofthecatheter.TheIVcathetershouldberemovedandanewIVlineinsertedatadifferentsite.Slowingtherateofinfusionandcheckingforloosecatheterconnectionsarenotcorrectresponses.Thehealthcareproviderwouldbenotifiedifphlebitisweretooccur,butthisisnottheinitialaction.TestTakingStrategy: Notethestrategicword,first.Focusonthedatainthequestion.Eliminateslowingtherateofinfusionandcheckingtheconnection,becausetheyarecomparableoralikeinthattheyindicatecontinuationofIVtherapy.Althoughthehealthcareproviderwouldbenotifiedofthisoccurrence,thewordfirstshoulddirectyoutoselecttheoptionofremovingtheIVcatheter.Reviewthesignsofphlebitisandtheactionstobetakenwhenitoccurs LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: IntravenousTherapyGiddensConcepts: ClinicalJudgment,InflammationHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,InflammationReference: Perry,A.,Potter,P.,&Ostendorf,W.(2014). Clinicalnursingskills&techniques (8 th ed.,p.707).St.Louis:Mosby.Awarded1.0pointsoutof1.0possiblepoints.2. 2. ID:9476963098Anursehangsa500mLbagofintravenous(IV)fluidforanassignedclient.Onehourlatertheclientcomplainsofchesttightness,isdyspneicandapprehensive,andhasanirregularpulse.TheIVbaghas100mLremaining.Whichactionshouldthenursetake first ?A. RemovetheIVB. SittheclientupinbedC. ShutofftheIVinfusion CorrectD. SlowtherateofinfusionRationale: Theclientssymptomsareindicativeofspeedshock,whichresultsfromtherapidinfusionofdrugsorabolusinfusion.Inthiscase,thenursewouldnotethat400mLhasinfusedover60minutes.ThefirstactiononthepartofthenurseisshuttingofftheIVinfusion.Otheractionsmayfollowinrapidsequence:Thenursemayelevatetheheadofthebedtoaidtheclientsbreathingandthenimmediatelynotifythehealthcareprovider.Slowingtheinfusionrateisinappropriatebecausetheclientwillcontinuetoreceivefluid.TheIVdoesnotneedtoberemoved.Itmaybeneededtomanagethecomplication.TestTakingStrategy: Notethequestioncontainsthestrategicwordfirst.RecognizingthesignsofspeedshockandrecallingtheappropriateinterventionsshouldalsodirectyoutotheoptionofshuttingofftheIVinfusion.Reviewtheinitialnursingactionsforspeedshock LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: CriticalCareGiddensConcepts: FluidandElectrolytes,PerfusionHESIConcepts: FluidandElectrolytes,PerfusionReference: Ignatavicius,D.,&Workman,M.(2013). Medicalsurgicalnursing:Patientcenteredcollaborativecare. (7 th ed.,p.230).St.Louis:Saunders.Awarded1.0pointsoutof1.0possiblepoints.3. 3. ID:9476961248Anursediscontinuesaninfusionofaunitofpackedredbloodcells(RBCs)becausetheclientisexperiencingatransfusionreaction.Afterdiscontinuingthetransfusion,whichactionshouldthenursetake next?A. RemovetheIVcatheterB. Contactthehealthcareprovider CorrectC. Changethesolutionto5%dextroseinwaterD. ObtainacultureofthetipofthecatheterdeviceremovedfromtheclientRationale: Ifthenursesuspectsatransfusionreaction,thetransfusionisstoppedandnormalsalinesolutioninfusedatakeepveinopenratependingfurtherhealthcareproviderprescriptions.Thenursethencontactsthehealthcareprovider. . Dextroseinwaterisnotused,becauseitmaycauseclottingorhemolysisofbloodcells.NormalsalinesolutionistheonlytypeofIVfluidthatiscompatiblewithblood.ThenursewouldnotremovetheIVcatheter,becausethentherewouldbenoIVaccessroutethroughwhichtotreatthereaction.Thereisnoreasontoobtainacultureofthecathetertip;thisisdonewhenaninfectionissuspected. TestTakingStrategy: Notethestrategicwordnext.KnowingthattheIVshouldnotberemovedwillassistyouintheeliminationprocess.RecallingthatnormalsalinesolutionistheonlytypeofIVfluidthatiscompatiblewithbloodwillalsohelpyouanswercorrectly.Toselectfromtheremainingoptions,notethatinfectionisnottheconcern;thiswillhelpyoueliminatetheoptionofobtainingacultureofthecathetertip.Reviewcareoftheclientexperiencingatransfusionreaction LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: BloodadministrationGiddensConcepts: ClinicalJudgment,PerfusionHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,PerfusionReference: Perry,A.,Potter,P.,&Ostendorf,W.(2014). Clinicalnursingskills&techniques (8 th ed.,pp.740741).St.Louis:Mosby.Awarded1.0pointsoutof1.0possiblepoints.4. 4. ID:9476963017Thenursedeterminesthattheclientisexhibitingsignsofahemolytictransfusionreactionwhilereceivingabloodtransfusion.Thenurseshouldperformtheseactionsinwhich priority order? Arrangetheactionsintheorderthattheyshouldbeperformed.Alloptionsmustbeused.CorrectA. StoppingtheinfusionofbloodB. HanginganIVbagofnormalsalinesolution(NS)atakeepveinopen(KVO)rateC. NotifyingthehealthcareproviderD. Obtainingvitalsigns/oxygensaturationE. DocumentingthefindingsRationale: Ifatransfusionreactionissuspected,thetransfusionisimmediatelystoppedandNSinfused,pendingfurtherprimaryhealthcareproviderprescriptions.EnsuringpatentIVaccessalsohelpsmaintaintheclientsintravascularvolume.NSisthesolutionofchoice,ratherthansolutionscontainingdextrose,becauseredbloodcellsdonotclumpwithNS.Next,theprimaryhealthcareprovidershouldbenotifiedbecausethisisanemergencysituation.Vitalsignsandoxygensaturationaremonitoredclosely.Finally,thenursedocumentsthefindingsandtheclientsresponsetotheinterventions.TestTakingStrategic: Notethestrategicword,priority.Notethattheclientisexperiencingahemolytictransfusionreactionanemergencycondition.Thequestionsetsforththeproblem;thenursemustdeterminetheorderinwhichinterventionsshouldbeperformed.First,thebloodtransfusionisstoppedandanisotonicsolutioninfused.Nextthenurseshouldnotifytheprimaryhealthcareprovider,checkvitalsignsandoxygensaturationdata,andassesstheclientclosely.Onceprescriptionsfromtheprimaryhealthcareproviderhavebeeninitiated,thenurseshoulddocumenttheeventandclientsresponse.ReviewtheprioritizationofinterventionsforatransfusionreactionLevelofCognitiveAbility: Applying ClientNeeds: PhysiologicalIntegrityIntegratedProcess: NursingProcess/ImplementationContentArea: BloodAdministrationGiddensConcepts:CareCoordination,ClinicalJudgmentHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,Collaboration/ManagingCare-CareCoordinationReference: Perry,A.,Potter,P.,&Ostendorf,W.(2014).Clinicalnursingskills&techniques(8thed.,pp.740741).St.Louis:Mosby. Awarded1.0pointsoutof1.0possiblepoints.2. 5. ID:9476964571Aclientwithheartfailureisbeinggivenfurosemideanddigoxin.Theclientcallsthenurseandcomplainsofanorexiaandnausea.Whichactionshouldthenursetake first?A. AdministeranantiemeticB. AdministerthedailydoseofdigoxinC. DiscontinuethemorningdoseoffurosemideD. Checktheresultoflaboratorytestingforpotassiumonthesampledrawn3hoursago CorrectRationale: Anorexiaandnauseaaresymptomscommonlyassociatedwithdigoxintoxicity,whichiscompoundedbyhypokalemia.Earlyclinicalmanifestationsofdigoxintoxicityincludeanorexiaandmildnausea,buttheyarefrequentlyoverlookedornotassociatedwithdigoxintoxicity.Hallucinationsandanychangeinpulserhythm,colorvision,orbehaviorshouldbeinvestigatedandreportedtothehealthcareprovider.Thenurseshouldfirstchecktheresultsofthepotassiumlevel,whichwillprovideadditionalwhenthenursecallsthehealthcareprovider , animportantfollowupaction.Thenurseshouldalsocheckthedigoxinreadingifoneisavailable.Thenursewouldnotadministeranantiemeticwithoutfurtherinvestigatingtheclientsproblem.Becausedigoxintoxicityissuspected,thenursewouldwithholdthedigoxinuntilthehealthcareproviderhasbeenconsulted.Thenursewouldnotdiscontinueamedicationwithoutaprescriptiontodoso.TestTakingStrategy: Notethestrategicwordfirstandusethestepsofthenursingprocesstoanswerthequestion.Thecorrectoptionistheonlyonethataddressesassessment.Reviewnursinginterventionsforsuspecteddigoxintoxicity LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: PharmacologyGiddensConcepts: CellularRegulation,ClinicalJudgmentHESIConcepts: CellularRegulation,ClinicalDecisionMaking/ClinicalJudgmentReferences: Hodgson,B.,&Kizior,R.(2015). Saundersnursingdrughandbook2015. (p.363)St.Louis:Saunders.Ignatavicius,D.,&Workman,M.(2013). Medicalsurgicalnursing:Patientcenteredcollaborativecare. (7 th ed.,p.753).St.Louis:Saunders.Awarded1.0pointsoutof1.0possiblepoints.2. 6. ID:9476961282Thehealthcareprovider(HCP)prescribestheadministrationoftotalparenteralnutrition(TPN),tobestartedatarateof50mL/hrbywayofinfusionpumpthroughanestablishedsubclaviancentralline.Afterthefirst2hoursoftheTPNinfusion,theclientsuddenlycomplainsofdifficultybreathingandchestpain.Thenurseshouldtakewhich immediate action?A. ObtainbloodforcultureB. ClamptheTPNinfusionline CorrectC. Obtainanelectrocardiogram(ECG)D. ObtainasampleforbloodglucosetestingRationale: Onecomplicationofasubclaviancentrallineisembolism,causedbyairorthrombus.SuddenonsetofchestpainshortlyaftertheinitiationofTPNmaymeanthatthiscomplicationhasdeveloped.Theinfusionisclamped(thelineshouldnotbediscontinued,however),theclientturnedontheleftsidewiththeheaddown,andtheHCPnotifiedimmediately.Dependingonagencyprotocol,therapidresponseteamwouldalsobecalled.Bloodculturesarenotnecessaryinthissituation,becauseinfectionisnottheconcern.Likewise,thereisnousefulreasonforcheckingthebloodglucoselevel.AnECGmaybeobtained,butthisisnottheimmediatepriority.Iftheclientshowssignsofanairembolism,thenurseshouldexaminethecathetertodeterminewhetheranopenporthasallowedairintothecirculatorysystem. TestTakingStrategy: Notethestrategicwordimmediate.Focusonthedataprovidedinthequestiontodeterminethatanembolushasoccurred.Eliminatebloodculturesandbloodglucosetesting,which,respectively,relatetoinfectionandhyperglycemia,whichisnotlikelytooccurduringthefirst2hoursofTPNadministration.Toselectfromtheremainingoptions,focusonthestrategicwordimmediate;thiswilldirectyoutothecorrectoption.ReviewthecomplicationsofTPNandtheassociatednursinginterventions LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: TotalParenteralNutritionGiddensConcepts: ClinicalJudgment,PerfusionHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,PerfusionClottingReference: Lewis,S.,Dirksen,S.,Heitkemper,M.,&Bucher,L.(2014). Medicalsurgicalnursing:Assessmentandmanagementofclinicalproblems (9 th ed.,p.311).St.Louis:Mosby.Awarded1.0pointsoutof1.0possiblepoints.3. 7. ID:9476957598Thehealthcareproviderprescribes2000mLof5%dextroseandnormalsaline0.45%forinfusionover24hours.Thedropfactoris15gtt/mL.Athowmanydropsperminutedoesthenursesettheflowrate? (Roundtothenearestwholenumber).CorrectCorrectResponsesA. 21Rationale: UsetheIVflowrateformula:TestTakingStrategy: Focusontheinformationinthequestion.UsetheformulaforcalculatingIVflowrateswhenansweringthequestion.Remembertoconvert24hourstominutesandtoroundtheanswertothenearestwholenumber.ReviewIVinfusionrates LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrityIntegratedProcess: NursingProcess/ImplementationContentArea: IntravenousTherapyGiddensConcepts: ClinicalJudgment,SafetyHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,SafetyReference: Perry,A.,Potter,P.,&Ostendorf,W.(2014). Clinicalnursingskills&techniques (8 th ed.,pp.710711).St.Louis:Mosby.Awarded1.0pointsoutof1.0possiblepoints.2. 8. ID:9476963091Anurseisassessingaperipheralintravenous(IV)siteandnotesblanching,coolness,andedemaattheinsertionsite.Whatshouldthenursedo first?A. RemovetheIV CorrectB. ApplyawarmcompressC. CheckforbloodreturnD. MeasuretheareaofinfiltrationRationale: Blanching,coolness,andedemaoftheIVsiteareallsignsofinfiltration.Becauseinfiltrationmayresultindamagetothesurroundingtissue,thenursemustfirstremovetheIVcannulatopreventanyfurtherdamage.Thenurseshouldnotdependsolelyonthebloodreturnforassurancethatthecannulaisinthevein,becausebloodreturnmaybepresentevenifthecannulaisonlypartiallyinthevein.Compressesmaybeused,butthecompress(warmorcool)dependsonthetypeofsolutioninfusingandhealthcareproviderpreference.ThenurseshouldmeasuretheareaofinfiltrationaftertheIVhasbeenremovedsothatfurthertissuedamageisprevented.TestTakingStrategy: Notethestrategicwordfirst.Althougheachoftheseoptionsisappropriate,itisnecessarytoprioritizethem.Thesignspresentedinthequestionpointtoinfiltration.InfiltrationindicatesthattheIVmustberemoved.Reviewthesignsofinfiltrationandtheappropriateinitialinterventions LevelofCognitiveAbility: ApplyingClientNeeds: PhysiologicalIntegrity IntegratedProcess: NursingProcess/ImplementationContentArea: IntravenousTherapyGiddensConcepts: ClinicalJudgment,InflammationHESIConcepts: ClinicalDecisionMaking/ClinicalJudgment,InflammationReference: Ignatavicius,D.,&Workman,M.(2013). Medicalsurgicalnursing:Patientcenteredcollaborativecare. (7 th ed.,p.228).St.Louis:Saunders.Awarded1.0pointsoutof1.0possiblepoints.2. 9. ID:9476964540Ahomecarenursehasbeenassignedaclientwhohasbeendischargedhomewithaprescriptionfortotalparenteralnutrition(TPN).WhichparametersdoesthenurseplantocheckateachvisitasameansofidentifyingcomplicationsoftheTPNtherapy? Selectallthatapply.A. Weight CorrectB.