2
Nclex- Cris-test 1 questions with accurate detailed solutions
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The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care,
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the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the
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MOST appropriate action for the nurse to take?
|| || || || || || ||
|| 1. Leave the cuff inflated and suction through the tracheostomy.
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|| 2. Deflate the cuff and suction through the tracheostomy tube.
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|| 3. Inflate the cuff pressure to 40 mm Hg before suctioning.
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4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - ✔✔1)
|| || || || || || || || || || || || || || || || ||
CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration;
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cuff position and pressure should be assessed frequently; swallowing and breathing will
|| || || || || || || || || || || ||
cause tracheostomy tube movement
|| || ||
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will
|| || || || || || || || || || || ||
drain into the bronchi; increased risk of infection
|| || || || || || ||
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25
|| || || || || || || || || || || || || || ||
cm H2O); risk of trauma to trachea with higher pressures
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4) Implementation: outcome not desired; increases the risk of trauma to lower airways
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A young adult brings a friend to the emergency department and states that the friend has
|| || || || || || || || || || || || || || || ||
been using heroin. Which action by the nurse is the MOST appropriate?
|| || || || || || || || || || ||
|| 1. Assess pupil size and reactivity.
|| || || || ||
|| 2. Assess oxygen saturation levels.
|| || || ||
|| 3. Palpate dorsalis pedis pulses.
|| || || ||
,2
4. Ask the client if he knows today's date. - ✔✔1) Assessment: outcome not priority but
|| || || || || || || || || || || || || || || || ||
may be appropriate; pinpoint pupils are a sign of heroin overdose
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2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas
|| || || || || || || || || || ||
exchange and possible respiratory arrest
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3) Assessment: outcome not priority; most important to assess airway and breathing
|| || || || || || || || || || ||
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may
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be seen; not priority
|| || ||
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
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(Nicorette). Which question is MOST important for the nurse to ask?
|| || || || || || || || || ||
|| 1. "Have you tried other methods to stop smoking?"
|| || || || || || || ||
|| 2. "How long have you been smoking?"
|| || || || || ||
|| 3. "Have you ever had chest pain?"
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4. "Do you have a partial dental bridge?" - ✔✔1) Assessment: outcome not priority but
|| || || || || || || || || || || || || || || ||
may be appropriate; can be asked as part of assessment
|| || || || || || || || ||
2) Assessment: outcome not priority but may be appropriate; should be assessed for further
|| || || || || || || || || || || || ||
teaching
||
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases
|| || || || || || || || || || || ||
heart rate and myocardial oxygen consumption; increased risk of angina and myocardial
|| || || || || || || || || || || ||
infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek
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and gums; may stain dental work
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,2
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
|| || || || || || || || || || || || || || ||
determines that the client has pressed the button 11 times and received 6 doses of
|| || || || || || || || || || || || || || ||
morphine during the last hour. Which is the MOST appropriate action for the nurse to take?
|| || || || || || || || || || || || || || ||
|| 1. Assess the patency of the PCA IV tubing.
|| || || || || || || ||
|| 2. Determine the client's understanding of the PCA pump function.
|| || || || || || || || ||
|| 3. Obtain an order to begin a PCA infusion of fentanyl.
|| || || || || || || || || ||
4. Ask the client to describe the pain. - ✔✔1) Assessment: outcome not priority but may
|| || || || || || || || || || || || || || || || ||
be appropriate; if tubing is obstructed, alarm is activated
|| || || || || || || ||
2) Assessment: outcome may be appropriate but not priority; more important to determine
|| || || || || || || || || || || || ||
pain level, description of the pain, region and radiation of the pain, and relieving factors
|| || || || || || || || || || || || || ||
3) Implementation: outcome not desired; more important to assess severity of pain and
|| || || || || || || || || || || || ||
pain relief first || ||
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
|| || || || || || || || || || || || || ||
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
|| || || || || || || || || || || ||
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the
|| || || || || || || || || || || || || ||
nurse is MOST appropriate? || || ||
|| 1. Place the client flat on her back.
|| || || || || || ||
|| 2. Elevate the head of the bed 30 degrees.
|| || || || || || || ||
|| 3. Place the client on her left side with her legs flexed.
|| || || || || || || || || || ||
4. Place the client supine with the foot of the bed elevated. - ✔✔1) Implementation:
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outcome not desired; no increase in venous return
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, 2
2) Implementation: outcome not desired; will decrease venous return
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3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
|| || || || || || || || || || || ||
output; fetal pressure on inferior vena cava reduced
|| || || || || || ||
4) Implementation: outcome not desired; elevation of legs will increase venous return, but
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fetal pressure on vena cava will prevent blood return to heart
|| || || || || || || || || ||
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration.
|| || || || || || || || || || || || || ||
Which finding BEST indicates improving fluid status?
|| || || || || ||
|| 1. Urinary output of 1,500 mL in 24 hours.
|| || || || || || || ||
|| 2. Serum hematocrit 52%.
|| || ||
|| 3. Oral fluid intake of 900 mL in 24 hours.
|| || || || || || || || ||
4. Blood pressure of 100/82. - ✔✔1) CORRECT - Assessment: outcome priority; increased
|| || || || || || || || || || || || || ||
amounts of antidiuretic hormone secreted; urine output decreased and concentrated
|| || || || || || || || ||
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
|| || || || || || || || ||
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
|| || || || || || || || || || || ||
4) Assessment: outcome not priority; normal BP is 120/80
|| || || || || || || ||
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
|| || || || || || || || || || || || || || || ||
morning. Which medication should the nurse question giving to the client?
|| || || || || || || || || ||
|| 1. 20 mg oral escitalopram (Celexa) in the morning.
|| || || || || || || ||
Nclex- Cris-test 1 questions with accurate detailed solutions
|| || || || || || ||
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care,
|| || || || || || || || || || || || || || ||
the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the
|| || || || || || || || || || || || || || || ||
MOST appropriate action for the nurse to take?
|| || || || || || ||
|| 1. Leave the cuff inflated and suction through the tracheostomy.
|| || || || || || || || ||
|| 2. Deflate the cuff and suction through the tracheostomy tube.
|| || || || || || || || ||
|| 3. Inflate the cuff pressure to 40 mm Hg before suctioning.
|| || || || || || || || || ||
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - ✔✔1)
|| || || || || || || || || || || || || || || || ||
CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration;
|| || || || || || || || || || || ||
cuff position and pressure should be assessed frequently; swallowing and breathing will
|| || || || || || || || || || || ||
cause tracheostomy tube movement
|| || ||
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will
|| || || || || || || || || || || ||
drain into the bronchi; increased risk of infection
|| || || || || || ||
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25
|| || || || || || || || || || || || || || ||
cm H2O); risk of trauma to trachea with higher pressures
|| || || || || || || || ||
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
|| || || || || || || || || || || ||
A young adult brings a friend to the emergency department and states that the friend has
|| || || || || || || || || || || || || || || ||
been using heroin. Which action by the nurse is the MOST appropriate?
|| || || || || || || || || || ||
|| 1. Assess pupil size and reactivity.
|| || || || ||
|| 2. Assess oxygen saturation levels.
|| || || ||
|| 3. Palpate dorsalis pedis pulses.
|| || || ||
,2
4. Ask the client if he knows today's date. - ✔✔1) Assessment: outcome not priority but
|| || || || || || || || || || || || || || || || ||
may be appropriate; pinpoint pupils are a sign of heroin overdose
|| || || || || || || || || ||
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas
|| || || || || || || || || || ||
exchange and possible respiratory arrest
|| || || || ||
3) Assessment: outcome not priority; most important to assess airway and breathing
|| || || || || || || || || || ||
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may
|| || || || || || || || || || || || ||
be seen; not priority
|| || ||
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
|| || || || || || || || || || || || || || ||
(Nicorette). Which question is MOST important for the nurse to ask?
|| || || || || || || || || ||
|| 1. "Have you tried other methods to stop smoking?"
|| || || || || || || ||
|| 2. "How long have you been smoking?"
|| || || || || ||
|| 3. "Have you ever had chest pain?"
|| || || || || ||
4. "Do you have a partial dental bridge?" - ✔✔1) Assessment: outcome not priority but
|| || || || || || || || || || || || || || || ||
may be appropriate; can be asked as part of assessment
|| || || || || || || || ||
2) Assessment: outcome not priority but may be appropriate; should be assessed for further
|| || || || || || || || || || || || ||
teaching
||
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases
|| || || || || || || || || || || ||
heart rate and myocardial oxygen consumption; increased risk of angina and myocardial
|| || || || || || || || || || || ||
infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek
|| || || || || || || || || || || || || ||
and gums; may stain dental work
|| || || || ||
,2
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
|| || || || || || || || || || || || || || ||
determines that the client has pressed the button 11 times and received 6 doses of
|| || || || || || || || || || || || || || ||
morphine during the last hour. Which is the MOST appropriate action for the nurse to take?
|| || || || || || || || || || || || || || ||
|| 1. Assess the patency of the PCA IV tubing.
|| || || || || || || ||
|| 2. Determine the client's understanding of the PCA pump function.
|| || || || || || || || ||
|| 3. Obtain an order to begin a PCA infusion of fentanyl.
|| || || || || || || || || ||
4. Ask the client to describe the pain. - ✔✔1) Assessment: outcome not priority but may
|| || || || || || || || || || || || || || || || ||
be appropriate; if tubing is obstructed, alarm is activated
|| || || || || || || ||
2) Assessment: outcome may be appropriate but not priority; more important to determine
|| || || || || || || || || || || || ||
pain level, description of the pain, region and radiation of the pain, and relieving factors
|| || || || || || || || || || || || || ||
3) Implementation: outcome not desired; more important to assess severity of pain and
|| || || || || || || || || || || || ||
pain relief first || ||
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
|| || || || || || || || || || || || || ||
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
|| || || || || || || || || || || ||
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the
|| || || || || || || || || || || || || ||
nurse is MOST appropriate? || || ||
|| 1. Place the client flat on her back.
|| || || || || || ||
|| 2. Elevate the head of the bed 30 degrees.
|| || || || || || || ||
|| 3. Place the client on her left side with her legs flexed.
|| || || || || || || || || || ||
4. Place the client supine with the foot of the bed elevated. - ✔✔1) Implementation:
|| || || || || || || || || || || || || || || ||
outcome not desired; no increase in venous return
|| || || || || || ||
, 2
2) Implementation: outcome not desired; will decrease venous return
|| || || || || || || ||
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
|| || || || || || || || || || || ||
output; fetal pressure on inferior vena cava reduced
|| || || || || || ||
4) Implementation: outcome not desired; elevation of legs will increase venous return, but
|| || || || || || || || || || || || ||
fetal pressure on vena cava will prevent blood return to heart
|| || || || || || || || || ||
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration.
|| || || || || || || || || || || || || ||
Which finding BEST indicates improving fluid status?
|| || || || || ||
|| 1. Urinary output of 1,500 mL in 24 hours.
|| || || || || || || ||
|| 2. Serum hematocrit 52%.
|| || ||
|| 3. Oral fluid intake of 900 mL in 24 hours.
|| || || || || || || || ||
4. Blood pressure of 100/82. - ✔✔1) CORRECT - Assessment: outcome priority; increased
|| || || || || || || || || || || || || ||
amounts of antidiuretic hormone secreted; urine output decreased and concentrated
|| || || || || || || || ||
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
|| || || || || || || || ||
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
|| || || || || || || || || || || ||
4) Assessment: outcome not priority; normal BP is 120/80
|| || || || || || || ||
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
|| || || || || || || || || || || || || || || ||
morning. Which medication should the nurse question giving to the client?
|| || || || || || || || || ||
|| 1. 20 mg oral escitalopram (Celexa) in the morning.
|| || || || || || || ||
