NCLEX RN TEST 1 NGN QUESTIONS AND
ANSWERS 100% CORRECT VERIFIED
ANSWERS
◉ For each finding below, click to specify if the finding is consistent
with the disease process of hemothorax or tension pneumothorax.
Each finding may support more than one disease process. Answer:
Hemothorax: results from the accumulation of blood loss in the
pleural cavity --> loss of intravascular blood vlolume: tachycardia,
hypotension, unilateral diminished breath sounds
Pneumothorax is characterized by air inside the pleural space, which
disrupts the negative pressure that maintains lung expansion, causing
the lung to collapse either partially or completely. Tension
pneumothorax develops if air enters but cannot escape the pleural
space --> this trapping compresses the heart and great vessels and
displaces the midline structures (trachea) to the opposite side. Tension
pneumothorax: tachycardia, hypotension, subcutaneous
emphysema/crepitus on palpitation (air gets into the tissue under the
skin), unilateral diminished breath sounds (also tracheal deviation,
hyperresonance to percussion)
Endoctracheal intubation would worsen the existing pneumothorax by
delivering positive pressure ventilation, which would increase
intrathoracic pressure ==> compress the heart and great vessels and
lead to cardiac arrest.
,◉ The charger nurse is responsible for making room assignments
multiple clients. Which pari of client assignments to a shared room is
appropriate? Answer: 3. Client who had a bowel resection 1 day ago
and client with asthma exacerbation.
When making room assignments, it is important to remember that a
client with an active or suspected infection should not be paired with
a client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is
not at risk for spreading infection to a client who had a recent bowel
resection surgery.
◉ The clinic nurse is assessing a client who is being treated for
depression and suicidal ideation. Which client statement best indicates
that the client is not currently at risk for suicide? Answer: 2. "I plan to
attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must
be carefully monitored for indications of increasing suicidal intent.
During a client interview, the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
,Clients who articulate long-term personal goals and family milestones
are less likely to attempt death by suicide
◉ The nurse is caring for a client who had an anterior wall
myocardial infarction 2 days ago. The telemetry technician notifies
the nurse at 8:30 AM that the client is in ventricular trigeminy. What
is the nurse's priority intervention? Answer: 1. Administer potassium
supplement
In ventricular trigeminy, premature ventricular contractions (PVCs)
occur every third heartbeat. Myocardial injury (eg, myocardial
infarction) predisposes the client to ectopy (eg, PVCs), which
increases the client's risk for lethal dysrhythmias (eg, ventricular
tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and
exercise.
This client's morning laboratory results show hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the
underlying cause of the ectopy by administering the prescribed
potassium replacement (Option 1). Health care providers (HCPs)
often prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics)
unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133
µmol/L], anuric, weight <99.2 lb [45 kg]).
◉ The nurse cares for a client with a terminal disease who created a
do not attempt resuscitation (DNAR) directive. The client stops
breathing and loses their pulse. The client's adult child states, "Please,
, do whatever you can to save them!" Which intervention is
appropriate? Answer: 3. Explain the client's resuscitation directive to
the client's child
Clients can create a do not attempt resuscitation (DNAR) directive
instructing that CPR and other life-saving measures be withheld. With
an advance directive in place, the client's wishes should be followed,
even if they conflict with the wishes of loved ones
◉ The nurse in the cardiac intensive care unit receives report on 4
clients. Which client should the nurse assess first? Answer: 2. Client
who underwent coronary artery stent placement via femoral approach
3 hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at
increased risk for retroperitoneal hemorrhage. Administration of
antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign),
hematoma formation, and diminished distal pulses can be early signs
of bleeding into the retroperitoneal space and require immediate
intervention (eg, notify health care provider, serial complete blood
count, CT scan of the abdomen)
◉ The nurse is reviewing the medical history of a client who has
sustained a right tibia/fibula fracture from a fall. The nurse identifies
ANSWERS 100% CORRECT VERIFIED
ANSWERS
◉ For each finding below, click to specify if the finding is consistent
with the disease process of hemothorax or tension pneumothorax.
Each finding may support more than one disease process. Answer:
Hemothorax: results from the accumulation of blood loss in the
pleural cavity --> loss of intravascular blood vlolume: tachycardia,
hypotension, unilateral diminished breath sounds
Pneumothorax is characterized by air inside the pleural space, which
disrupts the negative pressure that maintains lung expansion, causing
the lung to collapse either partially or completely. Tension
pneumothorax develops if air enters but cannot escape the pleural
space --> this trapping compresses the heart and great vessels and
displaces the midline structures (trachea) to the opposite side. Tension
pneumothorax: tachycardia, hypotension, subcutaneous
emphysema/crepitus on palpitation (air gets into the tissue under the
skin), unilateral diminished breath sounds (also tracheal deviation,
hyperresonance to percussion)
Endoctracheal intubation would worsen the existing pneumothorax by
delivering positive pressure ventilation, which would increase
intrathoracic pressure ==> compress the heart and great vessels and
lead to cardiac arrest.
,◉ The charger nurse is responsible for making room assignments
multiple clients. Which pari of client assignments to a shared room is
appropriate? Answer: 3. Client who had a bowel resection 1 day ago
and client with asthma exacerbation.
When making room assignments, it is important to remember that a
client with an active or suspected infection should not be paired with
a client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is
not at risk for spreading infection to a client who had a recent bowel
resection surgery.
◉ The clinic nurse is assessing a client who is being treated for
depression and suicidal ideation. Which client statement best indicates
that the client is not currently at risk for suicide? Answer: 2. "I plan to
attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must
be carefully monitored for indications of increasing suicidal intent.
During a client interview, the nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
,Clients who articulate long-term personal goals and family milestones
are less likely to attempt death by suicide
◉ The nurse is caring for a client who had an anterior wall
myocardial infarction 2 days ago. The telemetry technician notifies
the nurse at 8:30 AM that the client is in ventricular trigeminy. What
is the nurse's priority intervention? Answer: 1. Administer potassium
supplement
In ventricular trigeminy, premature ventricular contractions (PVCs)
occur every third heartbeat. Myocardial injury (eg, myocardial
infarction) predisposes the client to ectopy (eg, PVCs), which
increases the client's risk for lethal dysrhythmias (eg, ventricular
tachycardia). PVCs are caused and/or exacerbated by hypoxia,
electrolyte imbalances, emotional stress, stimulants, fever, and
exercise.
This client's morning laboratory results show hypokalemia (potassium
<3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the
underlying cause of the ectopy by administering the prescribed
potassium replacement (Option 1). Health care providers (HCPs)
often prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics)
unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133
µmol/L], anuric, weight <99.2 lb [45 kg]).
◉ The nurse cares for a client with a terminal disease who created a
do not attempt resuscitation (DNAR) directive. The client stops
breathing and loses their pulse. The client's adult child states, "Please,
, do whatever you can to save them!" Which intervention is
appropriate? Answer: 3. Explain the client's resuscitation directive to
the client's child
Clients can create a do not attempt resuscitation (DNAR) directive
instructing that CPR and other life-saving measures be withheld. With
an advance directive in place, the client's wishes should be followed,
even if they conflict with the wishes of loved ones
◉ The nurse in the cardiac intensive care unit receives report on 4
clients. Which client should the nurse assess first? Answer: 2. Client
who underwent coronary artery stent placement via femoral approach
3 hours ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and
intracoronary stent placement using the femoral approach is at
increased risk for retroperitoneal hemorrhage. Administration of
antithrombotic drugs before, during, and after PCI can exacerbate
potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign),
hematoma formation, and diminished distal pulses can be early signs
of bleeding into the retroperitoneal space and require immediate
intervention (eg, notify health care provider, serial complete blood
count, CT scan of the abdomen)
◉ The nurse is reviewing the medical history of a client who has
sustained a right tibia/fibula fracture from a fall. The nurse identifies
