NCLEX qsn from FB QUESTIONS WITH COMPLETE SOLUTIONS

The nurse provides care for a client diagnosed with right-sided heart failure. The nurse expects which assessment findings? (Select all that apply.) 1. Dependent edema. 2. Distended jugular veins. 3. Urinating less frequently. 4. Third heart sound (S 3). 5. Intermittent weight gain. 6. Dry, nonproductive cough. - 1) CORRECT— Right-sided heart failure is caused by failure of the right ventricle, which causes a backup of circulation. This results in dependent edema. 2) CORRECT— Venous jugular distention is caused by the increased venous pressure that occurs with right-sided heart failure. 5) CORRECT— Weight gain occurs due to fluid retention. Kidney perfusion is decreased by the weaker pumping of the heart, the kidneys react to the decreased perfusion by retaining sodium to increase fluid volume and pressure to increase perfusion. A weight gain of 2 lbs (0.91 kg) per day or 5 lbs (2.27 kg) in 1 week requires medication adjustments. 3) INCORRECT - Right-sided heart failure is accompanied by frequent urination, not less, especially at night. 4) INCORRECT - A third heart sound is found in left-sided heart failure, the result of a dilated left ventricle. A benign third heart sound is also sometimes heard in pregnancy, childhood, and in trained athletes. 6) INCORRECT - A dry cough is associated with initial left-sided heart failure. Right-sided heart failure is often the result of prolonged left-sided heart failure. Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator associated pneumonia? A. Uncuffed B. CASS C. Fenestrated D. Nasotracheal - B Nclex question! A patient has a Co2 of 52, what would be the nurse's immediate action? A) assess respiration b) do purse lip breathing C) prepare to intubate and ventilate D) place patient in semi Fowler position. - The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply) 1. Remove the newborn's eye patches during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. 3. Reposition the newborn every 4 hours. 4. Cover the newborn with light cotton clothing. 5. Cluster activities when caring for the newborn. - 1) CORRECT — The nurse should place eye patches over the newborn's eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings. 5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights. 2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin. 3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown. 4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights. During a well-child checkup, the nurse evaluates the reflexes of a client who is 6 months of age. Which finding is of concern to the nurse when observed? 1. Presence of a positive Babinski reflex. 2. Extrusion reflex when feeding. 3. Ability to grasp objects voluntarily. 4. Ability to roll from abdomen to back at will. - 2) CORRECT — The extrusion reflex disappears between 3 and 4 months of age. An infant uses this movement of the tongue as a normal reflex when anything touches the lips. It helps with sucking from a breast or bottle. 1) INCORRECT — A positive Babinski reflex disappears at approximately 1 year of age. The nurse would expect to observe it at 6 months. 3) INCORRECT — Grasping objects is a normal occurrence at this age. 4) INCORRECT — Rolling from the abdomen to the back is a normal occurrence at this age. A client receives gentamicin 500 mg every 8 hours IV for a leg infection. The nurse touches the client's shoulder when there is no response to a greeting. The client jumps and acts startled. Which action by the nurse is most important?