NCLEX Practice Questions — Set 32
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note on the electrocardiogram as a result of the laboratory value?
Show answer and rationale
Correct answer: D. U waves
A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life-threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms
The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which action is part of the plan for preparation and administration of the potassium?
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Correct answer: A. Preparing the medication for bolus administration
Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour
The nurse is reviewing laboratory results and notes that a client’s serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?
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Correct answer: C. Processed oat cereals
The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Nuts, cauliflower, and peas are good food sources of phosphorus. Peas are also a good source of magnesium. Processed foods are high in sodium content.
The nurse caring for a client with hypocalcemia would expect to note which change on the electrocardiogram (ECG)?
Show answer and rationale
Correct answer: D. Prolonged QT interval
The normal serum calcium level is 8.6 to 10 mg/dL. A serum calcium level lower than 8.6 mg/dL indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalem
The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L. Which finding would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
Show answer and rationale
Correct answer: A. Tall peaked T waves
A serum potassium level greater than 5.0 mEq/L indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.
The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
Show answer and rationale
Correct answer: D. The client who is taking diuretics
Hyponatremia is evidenced by a serum sodium level less than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?
Show answer and rationale
Correct answer: A. Hyperactive bowel sounds
Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.
The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level?
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Correct answer: D. Alcoholism
The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia
The nurse is reading a health care provider’s (HCP) progress notes in the client’srecord and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route?
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Correct answer: B. The skin
Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.
The nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for fluid volume excess?
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Correct answer: A. The client with kidney disease
A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit
The nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client’s laboratory report. The nurse understands that which client is most at risk for the development of a potassium value at this level?
Show answer and rationale
Correct answer: B. The client who has sustained a traumatic burn
A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?
Show answer and rationale
Correct answer: C. An increased pH with an increased
Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition
The nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder?
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Correct answer: B. Metabolic acidosis
Metabolic acidosis is defined as a total concentration of buffer base that is lower than normal, with a relative increase in the hydrogen ion concentration. This results from loss of buffer bases or retention of too many acids without sufficient bases, and occurs in conditions such as kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; or severe diarrhea. Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes, an ileostomy, or diarrhea. These conditions result in metabolic acidosis. The remaining options are incorrect interpretations and are not associated with the client with an ileostomy
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. On the basis of this documentation, which pattern did the nurse observe?
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Correct answer: C. Respirations that are abnormally deep, regular, and increased in rate
Kussmaul’s respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate.
The nurse notes that a client’s arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply.
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Correct answer: B. all the above
Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
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Correct answer: B. Potassium level of 3.0 mEq/L
Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia
The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance?
Show answer and rationale
Correct answer: A. Respiratory acidosis
Respiratory acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base disturbances can occur in a client with COPD during exacerbation of the disease, but the most likely imbalance is respiratory acidosis. The remaining options are incorrect. COPD is a respiratory condition, not a metabolic one. Respiratory alkalosis is associated with hyperventilation
The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier in the day and notes that the result is 2.4 ng/mL. The nurse should take which immediate action?
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Correct answer: D. Notify the health care provider (HCP).
The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The nurse should notify the HCP, who may give further prescriptions about holding further doses of digoxin. The option that indicates to record the normal value on the client’s flow sheet is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin levelexceeds the therapeutic range. Checking the client’s last pulse rate may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the client’s status may be more useful
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
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Correct answer: A. 15 mg/dL
The normal blood urea nitrogen level is 8 to 25 mg/dL. Values of 29 mg/dL and 35 mg/dL reflect continued dehydration. A value of 3 mg/dL reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. The nurse anticipates that which action is needed?
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Correct answer: B. Leaving the rate of the heparin infusion as is
The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client’s value should not be less than 30 seconds or greater than 90 seconds. Thus the client’s aPTT is within the therapeutic range and the dose should remain unchanged.
A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level, if noted in the client’s laboratory report, should be reported before administering the dose of furosemide?
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Correct answer: B. 3.2 mEq/L
The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which abnormal laboratory test results should the nurse report? Select all that apply.
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Correct answer: C. all theabove
The normal values include the following: calcium, 8.6 to 10 mg/dL; magnesium, 1.6 to 2.6 mg/dL; phosphorus, 2.7 to 4.5 mg/dL; neutrophils, 1800 to 7800 cells/mm3; serum creatinine, 0.6 to 1.3 mg/dL; and white blood cells, 4500 to 11,000 cells/mm3. The calcium level noted is low; the magnesium level noted is low; the phosphorus level noted is normal; the neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low
An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse evaluates the client’s status as being most satisfactory if the total protein is which value?
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Correct answer: D. 6.4 g/dL
The normal range for total serum protein level in the adult client is 6 to 8 g/dL. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. The options of 0.4 g/dL and 3.7 g/dL identify low values, and 9.8 g/dL identifies a high protein value
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?
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Correct answer: B. Preventing and recognizing hyperglycemia
In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes
A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?
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Correct answer: B. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy
The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse anticipates the client’s serum amylase level to be which value?
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Correct answer: C. 300 units/L
The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. The options of 45 units/L and 100 units/L are within normal limits. The option of 500 units/L is an extremely elevated level seen in acute pancreatitis
An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client’s history?
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Correct answer: C. Iron deficiency anemia
The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity
A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse should take which action after seeing the laboratory results?
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Correct answer: C. Place the normal report in the client’s medical record.
A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse should place the report containing the normal laboratory value in the client’s medical record. A platelet count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore bleeding precautions are not needed
The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which items from her menu?
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Correct answer: B. Oranges and dark green leafy vegetables
Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, b which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food item on the list?
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Correct answer: A. Cream cheese
Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Cream cheese is a high-fat food
The nurse instructs a client with chronic kidney disease who is receivinghemodialysis about dietary modifications. The nurse determines that the clientunderstands these dietary modifications if the client selects which items from the dietary menu?
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Correct answer: D. Cream of wheat, blueberries, coffee
The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. The food items in the remaining options are high in sodium, phosphorus, or potassium
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?
Show answer and rationale
Correct answer: D. Vitamin B12
Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet.
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
Show answer and rationale
Correct answer: C. Summer squash
Foods that are lower in sodium include fruits and vegetables (summer squash), because they do not contain physiological saline. Highly processed or refined foods (tomato soup, instant oatmeal) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium
The nurse is instructing a client with hypertension on the importance of choosingfoods low in sodium. The nurse should teach the client to limit intake of which food?
Show answer and rationale
Correct answer: A. Smoked sausage
Smoked foods are high in sodium, which is noted in the correct option. The remaining options are fruits and vegetables that are low in sodium.
A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?
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Correct answer: A. Decrease PN rate to 50 mL/hour.
When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not provide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia
A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?
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Correct answer: D. On the left side, with the head lower than the feet
Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected
Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour?
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Correct answer: D. Determine whether the client has an allergy to eggs.
The client beginning infusions of fat emulsions must be first assessed for known allergies to eggs to prevent anaphylaxis. Egg yolk is a component of the solution and provides emulsification. The remaining options are unnecessary and are not related to the administration of fat emulsion
A client is receiving parenteral nutrition (PN). The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia?
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Correct answer: A. Weakness, thirst, and increased urine output
The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul’s respirations, diuresis, and coma when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. The remaining options do not identify signs specific to hyperglycemia
The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item?
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Correct answer: B. Client’s temperature
Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change
The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?
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Correct answer: B. Obtains a different bottle of solution
Fat emulsion (lipids) is a white, opaque solution administered intravenously during parenteral nutrition therapy to prevent fatty acid deficiency. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers of fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Therefore the remaining options are inappropriate actions
A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?
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Correct answer: D. Send them to the laboratory for culture.
When the client who is receiving PN develops a fever, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect. Because culture for infectious organisms is necessary, the discontinued materials are not discarded or returned to the pharmacy or manufacturer
A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?
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Correct answer: A. Temperature and weight
The client receiving PN at home should have her or his temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection also could result in sepsis because the catheter is in a blood vessel. The client’s weight is monitored as a measure of the effectiveness of this nutritional therapy and to detect hypervolemia. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of PN.
The nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which client would be the least likely candidate for parenteral nutrition (PN)?
Show answer and rationale
Correct answer: B. A 42-year-old client who has had an open cholecystectomy
Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include those clients with burns, exacerbation of Crohn’s disease, and persistent nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery.
The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?
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Correct answer: D. Electronic infusion pump
The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client’s blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure.
The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit?
Show answer and rationale
Correct answer: B. 10% dextrose in water
The client is at risk for hypoglycemia; therefore the solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. The remaining options will not be as effective in minimizing the risk of hypoglycemia.
The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?
Show answer and rationale
Correct answer: B. Initiate a gentle upward tap on the cervix.
Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Options 1, 2, and 3 are not assessment techniques to check for ballottement. Option 2 is related to Hegar’s sign. Options 1 and 3 are a part of fetal assessment
A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?
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Correct answer: D. Crackles on auscultation of the lungs
Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume
The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?
Show answer and rationale
Correct answer: B. Secure all connections in the PN system.
The nurse should plan to secure all connections in the tubing (tape is used per agency protocol). This helps prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, monitoring the temperature and blood glucose levels does not relate to a risk for injury as presented in the question. In addition, the client’s temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively
A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?
Show answer and rationale
Correct answer: C. Hypervolemia
Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client’s signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia.
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
Show answer and rationale
Correct answer: D. Slow the IV infusion.
The client’s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication
The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?
Show answer and rationale
Correct answer: A. Rotate the bag gently.
After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last
The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation?
Show answer and rationale
Correct answer: A. Blood return shows in the backflash chamber of the catheter.
The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse’s insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return
The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?
Show answer and rationale
Correct answer: C. Phlebitis of the vein
Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, thetubing drops and the spike end hits the top of the medication cart. The nurse should take which action?
Show answer and rationale
Correct answer: B. Obtain new IV tubing.
The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag
A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?
Show answer and rationale
Correct answer: B. Sterile 2 x 2 gauze
A dry sterile dressing such as a sterile 2 x 2 is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase blood pressure?
Show answer and rationale
Correct answer: B. 5% dextrose in lactated Ringer’s
The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% extrose in lactated Ringer’s (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client’s blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis
The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?
Show answer and rationale
Correct answer: C. "I need to restrict my activity while this catheter is in place."
The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use.
A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client’s intravenous (IV) solution at 100 mL/hour?
Show answer and rationale
Correct answer: D. Portable chest x-ray film
Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure.
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 � F orally. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Delay hanging the blood and notify the health care provider (HCP).
If the client has a temperature higher than 100 � F, the unit of blood should not be hung until the HCP is notified and has the opportunity to give further prescriptions. The HCP likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse’s scope of practice to make. The nurse needs an HCP’s prescription to administer medications to the client
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?
Show answer and rationale
Correct answer: B. "Have you ever had a transfusion before?"
Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Questioning about previous history of shock and knowledge of complications and risks of transfusion are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, it is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client’s temperature is 100.8 � F orally from a baseline of 99.2 � F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
Show answer and rationale
Correct answer: A. Septicemia
Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
Show answer and rationale
Correct answer: C. Run normal saline at a keep-vein-open rate.
If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump
The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item?
Show answer and rationale
Correct answer: A. An in-line filter
The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. Tinted tubing is incorrect because blood does not need to be protected from light. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass.
A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?
Show answer and rationale
Correct answer: C. Decreased oozing of blood from puncture sites and gums
Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body
The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?
Show answer and rationale
Correct answer: B. Vital signs
A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are a priority just before beginning a transfusion
The 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?
Show answer and rationale
Correct answer: C. 15 minutes
The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a b 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, the remaining options are incorrect time frames
Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Place the client in high-Fowler’s position.
New onset of tachycardia, bounding pulses, and crackles and wheezes posttransfusion are evidence of fluid overload, a complication associated with blood transfusions. Placing the client in a high-Fowler’s (upright) position will facilitate breathing. Measures that increase blood return to the heart, such as leg elevation and administration of intravenous fluids, should be avoided at this time. In addition, administration of fluids cannot be initiated without a prescription. Consulting with the health care provider regarding administration of oxygen may be necessary, but positional changes take a short amount of time to do and should be initiated first
The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?
Show answer and rationale
Correct answer: B. White blood cell count
The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts and differential to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells
A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Fresh-frozen plasma is prescribed and transfused to replace fluid and blood loss. The nurse understands that which is the rationale for transfusing fresh-frozen plasma to this client?
Show answer and rationale
Correct answer: C. To promote rapid volume expansion
Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level
The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which item is important to check regarding the age of blood cells before the transfusion is begun?
Show answer and rationale
Correct answer: C. Expiration date
The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client’s name. The nurse also inspects the unit of blood for leaks, abnormal color, clots, and bubbles and returns the unit to the blood bank if clots are noted.
A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which action(s) to reduce the risk of possible transfusion complications? Select all that apply.
Show answer and rationale
Correct answer: A. a and b
A donation of the client’s own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery
A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?
Show answer and rationale
Correct answer: C. Blood-warming device
If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood with a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client’s bedside?
Show answer and rationale
Correct answer: C. 0.9% sodium chloride
Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer’s is not the solution of choice with this procedure.
The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?
Show answer and rationale
Correct answer: D. Contact the electrical maintenance department for assistance.
Electrical equipment must be maintained in good working order and should be grounded; otherwise it presents a physical hazard. An intravenous line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard
The nurse obtains a prescription from a health care provider to restrain a clientand instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP?
Show answer and rationale
Correct answer: A. Safely securing the safety device straps to the side rails
The safety device straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and one or two fingers should slide easily between the safety device and the client’s skin
The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply.
Show answer and rationale
Correct answer: B. all the above
Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or from animal to person, and it is not contracted via bites from ticks or deer flies.
The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?
Show answer and rationale
Correct answer: A. Every 30 minutes
The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed
The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan?
Show answer and rationale
Correct answer: C. Placing the client in a semiprivate room at the end of the hallway
A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure
Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?
Show answer and rationale
Correct answer: C. Gloves, gown, goggles, and face shield
Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary
The nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?
Show answer and rationale
Correct answer: C. Activate the fire alarm.
The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished
A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?
Show answer and rationale
Correct answer: D. Call the Poison Control Center.
If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department and, if this is the case, the mother should call an ambulance
The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action?
Show answer and rationale
Correct answer: B. Activate the emergency response plan.
In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the emergency department for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur
The nurse on the day shift walks into a client’s room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
Show answer and rationale
Correct answer: C. Start chest compressions.
The next nursing action would be to start chest compressions. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim’s airway
The nurse witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method?
Show answer and rationale
Correct answer: C. Jaw thrust maneuver
If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.
The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider (HCP)?
Show answer and rationale
Correct answer: A. Each rescue breath should be given over 1 second and should produce a visible chest rise.
In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. HCPs should employ a 30:2 compression-to-ventilation ratio for the adult victim
The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standingbehind the child, placing her arms under the child’s axillae and around the child, and positioning her hands to deliver the thrusts between which areas?
Show answer and rationale
Correct answer: C. Umbilicus and the xiphoid process
To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim’s axillae and around the victim. The rescuer places the thumb side of one fist against the victim’s abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs
The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child?
Show answer and rationale
Correct answer: B. 43259
In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered. Test-Taking Strategy: Focus on the subject, rescue breathing and breaths per second. Note the age of the child. Recalling the normal respiratory rate in a child at this age and focusing on the subject, breaths per second, will assist in directing you to the correct option
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, the nurse compresses at least how many times?
Show answer and rationale
Correct answer: C. 100 times per minute
In an infant, the rate of chest compressions is at least 100 times per minute.
The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands this reason if the student makes which statement?
Show answer and rationale
Correct answer: C. "The object may be forced back farther into the throat."
Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object farther down into the airway. The other options do not identify reasons for avoiding blind finger sweeps
The nurse witnesses the collapse of a victim in her neighborhood and suspectscardiac arrest. Which action should the nurse take first?
Show answer and rationale
Correct answer: D. Activate the emergency response system.
If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response system. Next, the nurse should obtain an automated external defibrillator, followed by initiation of cardiopulmonary resuscitation, beginning with chest compressions
The nursing instructor asks a nursing student to describe the procedure for performing abdominal thrusts on an unconscious pregnant woman at 32 weeks’ gestation. The student describes a component of the procedure correctly if the student states that he will take which action?
Show answer and rationale
Correct answer: D. Place a rolled blanket under the right abdominal flank and hip area
If an unconscious woman in an advanced gestational stage of pregnancy has a foreign body airway obstruction, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. This prevents supine hypotension that can occur if the gravid uterus rests on the vena cava. The rescuer then attempts ventilations; if ventilation is unsuccessful, the rescuer positions the hands as for chest compressions and delivers firm chest thrusts to remove the obstruction. Placing the hands on the pelvis or abdomen and performing left lateral abdominal thrusts are ineffective and could be harmful
The nurse is performing cardiopulmonary resuscitation (CPR) on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)?
Show answer and rationale
Correct answer: D. 2 inches
When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant it is 11?2 inches
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Show answer and rationale
Correct answer: A. Urinary output of 20 mL/hour
Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 � C (100 � F) or lower than 36.1 � C (97 � F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client’s preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?
Show answer and rationale
Correct answer: B. Pneumonia
Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioidanalgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
Show answer and rationale
Correct answer: A. Obtain a telephone consent from a family member, following agency policy
Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member’s oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
Show answer and rationale
Correct answer: D. "Can you share with me what you’ve been told about your surgery?"
Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client’s anxiety. Explaining the entire surgical procedure may increase the client’s anxiety. Option 4 avoids the client’s anxiety and is focuses on postoperative care
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?
Show answer and rationale
Correct answer: C. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler’s or high Fowler’s position. The mouthpiece should be covered completely and tightly while the client nhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly
The nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
Show answer and rationale
Correct answer: A. Serous drainage
Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication?
Show answer and rationale
Correct answer: B. Increasing restlessness
Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon’s office by the nurse, knowing that it could cause surgery to be postponed?
Show answer and rationale
Correct answer: B. Hemoglobin, 8.0 g/dL
Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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