NCLEX RN exam u world questions
The nurse is caring for a client with surgical complications who requires
continuous total parenteral nutrition (TPN). The nurse assists the health care
provider with the insertion of a subclavian triple lumen central venous
access device. What is the priority action before initiating the TPN infusion?
correct answersCheck the results of the portable chest x-ray.
Defense mechanisms correct answersStrategies or responses, usually
unconscious, used by individuals to distance themselves from a full
awareness of unpleasant thoughts, internal conflicts, and external
stresses. Protect the ego from threatening thoughts and anxiety.
A client recently admitted to an inpatient unit for treatment of alcoholism
says to the nurse, "I only came here to get away from my nagging spouse.
Sometimes I think my spouse is the one who should be here. I can stop
drinking anytime I want." The nurse recognizes that the client is exhibiting
which of the following defense mechanisms? correct answersDenial and
projection
Defense mechanism: rationalization correct answersUsing excuses to
explain away threatening circumstances
- "I did poorly on the test because the questions were so tricky."
Defense mechanism: Displacement correct answersTransferring thoughts
and feelings toward one person or object onto another person or object.
- A person who is angry with a boss comes home and yells at the spouse
Defense mechanism: Regression correct answersReturning to a
previous level of development
- An adult has a temper tantrum when stuck in traffic
Defense mechanism: Introjection correct answersTaking on the qualities or
attitudes of others without thought or examination
- A parent who is resentful of an unplanned child becomes overprotective of
that child
Defense mechanism: Repression correct answersKeeping unacceptable
thoughts or traumatic events buried in the unconscious
- A person who was raped cannot recall the event
Defense mechanism: Sublimation correct answersTransforming
unacceptable thoughts or needs into acceptable actions
- A person may turn to boxing to deal with agression
, Defense mechanism: Denial correct answersThe refusal to accept the
reality of threatening situations, or painful thoughts, feelings, or
events.
- the most frequent mechanism used by clients with alcoholism
The nurse receives laboratory reports on 4 clients. Which report is most
concerning and should be reported to the health care provider? correct
answersThe client who had a total knee replacement 2 hours ago and whose
hemoglobin is 7 g/dL (70 g/L)
-a very low hemoglobin means the client needs to be assessed for any
active bleeding as well as for respiratory and cardiac complications (eg,
rapid pulse, SOB).
Normal hemoglobin levels correct answersAdult male: 13.2-
17.3 g/dL Adult female: 11.7-15.5 g/dL
Normal PaCO2 correct answers35-45 mm Hg
-clients with asthma exacerbations as well as those with panic attacks,
pulmonary embolism and pneumonia will have rapid breathing - which
pushes more CO2 out of the lungs. A mild decrease in PaCO2 is the expected
compensatory response.
-In these clients, retention of CO2, or even a normal PaCO2, is more
dangerous, as it indicates respiratory muscle fatigue or failure, resulting in
retention of PaCO2.
Normal PaO2 correct answers>80 mm Hg
-In clients with chronic obstructive pulmonary disease, airflow out of the
lungs is impeded, trapping CO2 in the lungs. The body adjusts to the higher
CO2 level, which would cause an increase in respirations in a non-COPD
client, and then uses the PaO2 as the drive for breathing.
The nurse is caring for an infant diagnosed with Hirschsprung disease who
is awaiting surgery. Which assessment finding requires the nurse's
immediate action? correct answersEpisode of foul-smelling diarrhea and
fever.
-A potentially fatal complication is Hirschsprung enterocolitis, an
inflammation of the colon, which can lead to sepsis and death. Enterocolitis
will present with fever, lethargy; explosive, foul-smelling diarrhea; and
rapidly worsening abdominal distention.
Hirschsprung disease HD correct answersOccurs when a child is born with
some sections of the distal large intestine missing nerve cells, rendering the
internal anal sphincter unable to relax. As a result, there is no peristalsis and
stool is not passed. These newborns exhibit symptoms of distal intestinal
obstruction. They also have a distended abdomen and will not pass
meconium within the expected 24-48 hours. They also have difficulty
feeding and often vomit green bile. Surgical removal of the defective section
of bowel is necessary and colostomy may be required.
The nurse is planning a client care conference with the parents of a 3-
year-old with newly diagnosed type 1 diabetes mellitus. What is the
priority outcome for the caregivers? correct answersKnowing how to
keep blood sugars stable.
The nurse is caring for a client with surgical complications who requires
continuous total parenteral nutrition (TPN). The nurse assists the health care
provider with the insertion of a subclavian triple lumen central venous
access device. What is the priority action before initiating the TPN infusion?
correct answersCheck the results of the portable chest x-ray.
Defense mechanisms correct answersStrategies or responses, usually
unconscious, used by individuals to distance themselves from a full
awareness of unpleasant thoughts, internal conflicts, and external
stresses. Protect the ego from threatening thoughts and anxiety.
A client recently admitted to an inpatient unit for treatment of alcoholism
says to the nurse, "I only came here to get away from my nagging spouse.
Sometimes I think my spouse is the one who should be here. I can stop
drinking anytime I want." The nurse recognizes that the client is exhibiting
which of the following defense mechanisms? correct answersDenial and
projection
Defense mechanism: rationalization correct answersUsing excuses to
explain away threatening circumstances
- "I did poorly on the test because the questions were so tricky."
Defense mechanism: Displacement correct answersTransferring thoughts
and feelings toward one person or object onto another person or object.
- A person who is angry with a boss comes home and yells at the spouse
Defense mechanism: Regression correct answersReturning to a
previous level of development
- An adult has a temper tantrum when stuck in traffic
Defense mechanism: Introjection correct answersTaking on the qualities or
attitudes of others without thought or examination
- A parent who is resentful of an unplanned child becomes overprotective of
that child
Defense mechanism: Repression correct answersKeeping unacceptable
thoughts or traumatic events buried in the unconscious
- A person who was raped cannot recall the event
Defense mechanism: Sublimation correct answersTransforming
unacceptable thoughts or needs into acceptable actions
- A person may turn to boxing to deal with agression
, Defense mechanism: Denial correct answersThe refusal to accept the
reality of threatening situations, or painful thoughts, feelings, or
events.
- the most frequent mechanism used by clients with alcoholism
The nurse receives laboratory reports on 4 clients. Which report is most
concerning and should be reported to the health care provider? correct
answersThe client who had a total knee replacement 2 hours ago and whose
hemoglobin is 7 g/dL (70 g/L)
-a very low hemoglobin means the client needs to be assessed for any
active bleeding as well as for respiratory and cardiac complications (eg,
rapid pulse, SOB).
Normal hemoglobin levels correct answersAdult male: 13.2-
17.3 g/dL Adult female: 11.7-15.5 g/dL
Normal PaCO2 correct answers35-45 mm Hg
-clients with asthma exacerbations as well as those with panic attacks,
pulmonary embolism and pneumonia will have rapid breathing - which
pushes more CO2 out of the lungs. A mild decrease in PaCO2 is the expected
compensatory response.
-In these clients, retention of CO2, or even a normal PaCO2, is more
dangerous, as it indicates respiratory muscle fatigue or failure, resulting in
retention of PaCO2.
Normal PaO2 correct answers>80 mm Hg
-In clients with chronic obstructive pulmonary disease, airflow out of the
lungs is impeded, trapping CO2 in the lungs. The body adjusts to the higher
CO2 level, which would cause an increase in respirations in a non-COPD
client, and then uses the PaO2 as the drive for breathing.
The nurse is caring for an infant diagnosed with Hirschsprung disease who
is awaiting surgery. Which assessment finding requires the nurse's
immediate action? correct answersEpisode of foul-smelling diarrhea and
fever.
-A potentially fatal complication is Hirschsprung enterocolitis, an
inflammation of the colon, which can lead to sepsis and death. Enterocolitis
will present with fever, lethargy; explosive, foul-smelling diarrhea; and
rapidly worsening abdominal distention.
Hirschsprung disease HD correct answersOccurs when a child is born with
some sections of the distal large intestine missing nerve cells, rendering the
internal anal sphincter unable to relax. As a result, there is no peristalsis and
stool is not passed. These newborns exhibit symptoms of distal intestinal
obstruction. They also have a distended abdomen and will not pass
meconium within the expected 24-48 hours. They also have difficulty
feeding and often vomit green bile. Surgical removal of the defective section
of bowel is necessary and colostomy may be required.
The nurse is planning a client care conference with the parents of a 3-
year-old with newly diagnosed type 1 diabetes mellitus. What is the
priority outcome for the caregivers? correct answersKnowing how to
keep blood sugars stable.
