Nclex-Rn Practice Questions-Physıologıcal Integrıty-Reduction Of Risk Potential Part 1
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Question 1 |
A client presents to the emergency department with complaint of severe indigestion. The physician orders diagnostic tests to confirm cholecystitis. The nurse anticipates that the physician will order which test?
A | Abdominal computed tomography (CT) scan. |
B | Abdominal ultrasound. |
C | Barium swallow. |
D | Colonoscopy. |
Question 2 |
A nurse is caring for a client with a central line catheter that is attached to a monitor to observe central venous pressure (CVP). The client’s wife asks what the CVP measures. The nurse states:
A | The CVP measures the pressure within the lungs. |
B | The CVP is a measure of blood volume status. |
C | The CVP measures how much blood the heart pumps. |
D | The CVP measures the heart rate. |
Question 3 |
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can be differentiated from diabetic ketoacidosis (DK) by which physiologic finding?
A | Increased serum osmolarity. |
B | Hypokalemia. |
C | Hyperglycemia. |
D | Absence of ketosis. |
Question 4 |
The nurse changes a wet-to-dry dressing for a client who has a pressure ulcer with infected, necrotic tissue. The nurse knows the purpose of the wet-to-dry dressing is to:
A | Prevent extensive infection. |
B | Reduce pain. |
C | Debride the wound. |
D | Keep the wound moist. |
Question 5 |
The physician orders a continuous positive airway pressure (CPAP) mask for a client. The nurse explains to the client that CPAP provides:
A | Extra oxygen. |
B | A constant flow of oxygen. |
C | Pressurized oxygen at the end of expiration to open collapsed alveoli. |
D | Pressurized oxygen so the client can breathe more easily. |
Question 6 |
The nurse is caring for a client who is receiving intravenous conscious sedation. Which is the nurse’s priority?
A | Monitoring level of consciousness. |
B | Monitoring urine output. |
C | Monitoring for lower extremity edema. |
D | Monitoring temperature. |
Question 7 |
The nurse is instructing a client with chronic obstructive pulmonary disease (COPD) how to perform pursed-lip breathing. The nurse determines the client understands the instructions when the nurse observes the client:
A | Lying flat and inhaling deeply and exhaling slowly. |
B | Sitting in an upright position, inhaling deeply and exhaling slowly through slightly closed lips. |
C | Sitting with arms draped over the over-bed table and breathing normally. |
D | Inhaling, holding the breath, and then exhaling forcefully. |
Question 8 |
The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find?
A | Increased white blood cells. |
B | Presence of protein. |
C | Presence of ketones. |
D | Increased specific gravity. |
Question 9 |
A client’s echocardiogram indicates vegetation on the heart valves. The nurse knows that the vegetation may be caused by which condition?
A | Diabetes mellitus. |
B | Myocardial infarction. |
C | Bacterial infection. |
D | Hypertension. |
Question 10 |
The nurse is preparing a client for a colonoscopy the following morning. The nurse should expect to administer which medication to the client?
A | Vitamin K. |
B | Warfarin (Coumadin). |
C | Polyethylene glycol electrolyte solution (GoLytely). |
D | Calcium carbonate (Tums). |
Question 11 |
Which test is most commonly used to determine the area of myocardial damage during or after a myocardial infarction (MI)?
A | Cardiac catheterization. |
B | Cardiac enzymes. |
C | Echocardiogram. |
D | Electrocardiogram. |
Question 12 |
The nurse collects a urine specimen from a client’s indwelling urinary catheter. Which method is the correct procedure for obtaining a urine specimen from an indwelling urinary catheter?
A | Place a new drainage bag on the catheter and collect the specimen from the bag. |
B | Disconnect the catheter tubing from the drainage bag and drain urine from the tubing into a specimen cup. |
C | Remove the catheter and insert a straight catheter to collect the specimen. |
D | Clean the sampling port on the catheter with an alcohol pad and insert a sterile needle with syringe into the port. |
Question 13 |
The nurse is preparing a client for a lumbar puncture. Which is the appropriate position for the client?
A | Prone with a pillow under the abdomen. |
B | Side-lying. |
C | Side-lying with chin to chest and knees pulled up to chest. |
D | Side-lying in semi-Fowler’s position. |
Question 14 |
The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse’s teaching?
A | I’ll have to take a strong laxative the night before the test. |
B | I’ll have to drink contrast while x-rays are taken. |
C | I’ll have a CT scan after I’m injected with a radiopaque contrast dye. |
D | The doctor will pass an instrument through my mouth to my stomach. |
Question 15 |
The nurse prepares a client for a bedside thoracentesis. The nurse helps the client into a sitting position with a pillow placed on top of the overbed table in front of the client for support. The nurse understands that this is the correct client position for a thoracentesis because:
A | It is less painful for the client. |
B | It allows for maximal lung expansion. |
C | Fluid will accumulate at the base of the pleural cavity. |
D | There is a risk of a pneumothorax. |
Question 16 |
A client comes to the emergency department with sudden onset of shortness of breath. The client’s condition deteriorates quickly. The physician suspects a pulmonary embolism. The nurse can expect the physician to order which test?
A | Chest x-ray. |
B | Ultrasound of chest. |
C | Pulmonary function tests. |
D | Ventilation perfusion (VQ) scan. |
Question 17 |
The nurse working in the emergency department is caring for a client with suspected acute myocardial infarction. STAT blood tests are ordered. Which test result should the nurse be most concerned?
A | CK-MB 3%. |
B | Hematocrit 42%. |
C | Erythrocyte sedimentation rate 10 mm/h. |
D | Glucose 115 mg/dL. |
Question 18 |
A client experiences partial-thickness burns to both lower extremities and portions of the trunk. Which intravenous fluids should the nurse expect to administer to this client?
A | Albumin. |
B | Dextrose 5% in water (D5W). |
C | Normal saline with potassium. |
D | Lactated Ringer’s (LR) solution. |
Question 19 |
A client starts filgrastim (Neupogen) injections 11 days after completing a course of chemotherapy. Which lab value indicates the neupogen is effective?
A | Absolute neutrophil count 1100/mm3. |
B | Absolute neutrophil count 750/mm3. |
C | Hemoglobin 10 g/dL. |
D | Hemoglobin 6.5 g/dL. |
Question 20 |
The nurse teaches a client how to collect urine for a 24-hour urine collection for protein and creatinine clearance. The nurse knows the client understands how to collect urine when the client states:
A | I will throw out my first void of the morning and then start my collection. |
B | I will collect all of my urine for 24 hours. |
C | If I don’t collect some of my urine, the test results will still be accurate. |
D | I must collect urine midstream. |
Question 21 |
A client experiences nausea and vomiting for over 24 hours. The nurse notices that the client is becoming confused and lethargic. As the nurse goes to call the physician, the client has a seizure. Which electrolyte abnormality should the nurse expect to see?
A | Hypocalcemia. |
B | Hyponatremia. |
C | Increased lipase. |
D | Hyperkalemia. |
Question 22 |
Which sign or symptom should a nurse most likely assess in a client with a magnesium level of 2.9 mEq/L?
A | Positive Homan’s sign. |
B | Tetany. |
C | Loss of deep tendon reflexes. |
D | Twitching. |
Question 23 |
After reviewing morning laboratory data belonging to a trauma client, the nurse notices that the client’s potassium is 5.6 mEq/L. The nurse should immediately:
A | Attach the client to a heart monitor and obtain vital signs. |
B | Call the physician. |
C | Call the emergency response team. |
D | Begin chest compressions. |
Question 24 |
A client’s platelet count is 70,000/mm3. The nurse instructs the client to:
A | Avoid crowds. |
B | Use an electric razor to shave. |
C | Increase calcium intake. |
D | Drink plenty of fluids. |
Question 25 |
The nurse reviews arterial blood gas results for his client with chronic obstructive pulmonary disease (COPD). The pH is 7.3, PaCO2 is 56 mm Hg, and HCO3 is 24 mEq/L. Which acid–base imbalance is this client experiencing?
A | Respiratory acidosis. |
B | Metabolic acidosis. |
C | Respiratory alkalosis. |
D | Metabolic alkalosis. |
Question 26 |
The nurse reviews a client’s arterial blood gas results. The results are as follows: pH is 7.6, PaCO2 is 37 mm Hg, and HCO3 is 32 mEq/L. Which acid–base imbalance is this client experiencing?
A | Metabolic acidosis. |
B | Metabolic alkalosis. |
C | Respiratory acidosis. |
D | Respiratory alkalosis. |
Question 27 |
The nurse instructs a client with newly diagnosed diabetes mellitus that hypoglycemia occurs when the blood sugar level is less than:
A | 100 mg/dL. |
B | 58 mg/dL. |
C | 75 mg/dL. |
D | 140 mg/dL. |
Question 28 |
A nurse cares for a client with hyperthyroidism whose serum calcium level is 11.7 mg/dL. Which medication should the nurse anticipate being ordered for this client?
A | Vitamin D. |
B | Calcium chloride. |
C | Calcium gluconate. |
D | Calcitonin. |
Question 29 |
A client’s sodium is 122 mEq/L. Which action is a priority nursing intervention?
A | Obtaining vital signs every 15 minutes. |
B | Increasing fluid intake. |
C | Initiating seizure precautions. |
D | Implementing cardiac monitoring. |
Question 30 |
A client’s potassium level is 5.38 mEq/L. Which drug should the nurse expect the physician to order?
A | Furosemide (Lasix). |
B | Sodium polystyrene sulfonate (Kayexalate). |
C | Potassium (K-Dur). |
D | Magnesium citrate (Citroma). |
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