NSG 4800 NCLEX
GALEN COLLEGE
QUESTIONS AND ANSWERS
VERIFIED AND GRADED A+
,The nurse is caring for a client with diabetic ketoacidosis and documents that the
client is experiencing Kussmaul's respirations. Which patterns did the nurse
observe? Select all that apply.
1. Respirations that are shallow
2. Respirations that are increased rate
3. Respirations that are abnormally slow
4. Respirations that are abnormally deep
5. Respirations that cease for several seconds
Answers: 2 and 4
Rationale: Kussmaul's respirations are abnormally deep and increased in rate.
These occur as a result of the compensatory action by the lungs. In bradypnea,
respirations are regular but abnormally slow. Apnea is described as respirations
that cease for several seconds.
A client who had a major stroke is prescribed aspirin, 81 mg, and Clopidogrel. The
nurse realizes that the drug classification of Clopidogrel is
1. anticoagulant.
2. intravenous anticoagulant.
3. antiplatelet.
4. thrombolytic.
,Answer: 3 Clopidogrel is an antiplatelet.
An intravenous anticoagulant would be heparin.
Clop - change to CLOT helps me not have a clot
The nurse is preparing to change the parenteral nutrition (PN) solution bag and
tubing. The client's central venous line is located in the right subclavian vein. The
nurse asks the client to take which essential action during the tubing change?
A. Breathe normally.
B. Turn the head to the right.
C. Exhale slowly and evenly.
D. Take a deep breath, hold it, and bear down.
Answer: D.
The client should be asked to perform the Valsalva maneuver during tubing
changes. This helps avoid air embolism during tubing changes. The nurse asks the
client to take a deep breath, hold it, and bear down. If the intravenous line is on
the right, the client turns his or her head to the left. This position increases
intrathoracic pressure. Breathing normally and exhaling slowly and evenly are
inappropriate and could enhance the potential for an air embolism during the
tubing change.
, The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should
the nurse include for this type of assessment? Select all that apply.
1. Auscultating lung sounds
2. Obtaining client's temperature
3. Assessing the strength of peripheral pulses
4. Obtaining information about the client's respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or disease
Answers: 1, 2, 4
Rationale: A focused assessment focuses on a limited or short-term problem, such
as the client's complaint. Because the client is complaining of symptoms of a cold,
a cough, and lung congestion, the nurse would focus on the respiratory system
and the presence of an infection. A complete assessment includes a complete
health history and physical examination and forms a baseline database. Assessing
the strength of peripheral pulses relates to a vascular assessment, which is not
related to this client's complaints. A musculoskeletal and neurological examination
also is not related to this client's complaints. However, strength of peripheral
pulses and a musculoskeletal and neurological examination would be included in a
GALEN COLLEGE
QUESTIONS AND ANSWERS
VERIFIED AND GRADED A+
,The nurse is caring for a client with diabetic ketoacidosis and documents that the
client is experiencing Kussmaul's respirations. Which patterns did the nurse
observe? Select all that apply.
1. Respirations that are shallow
2. Respirations that are increased rate
3. Respirations that are abnormally slow
4. Respirations that are abnormally deep
5. Respirations that cease for several seconds
Answers: 2 and 4
Rationale: Kussmaul's respirations are abnormally deep and increased in rate.
These occur as a result of the compensatory action by the lungs. In bradypnea,
respirations are regular but abnormally slow. Apnea is described as respirations
that cease for several seconds.
A client who had a major stroke is prescribed aspirin, 81 mg, and Clopidogrel. The
nurse realizes that the drug classification of Clopidogrel is
1. anticoagulant.
2. intravenous anticoagulant.
3. antiplatelet.
4. thrombolytic.
,Answer: 3 Clopidogrel is an antiplatelet.
An intravenous anticoagulant would be heparin.
Clop - change to CLOT helps me not have a clot
The nurse is preparing to change the parenteral nutrition (PN) solution bag and
tubing. The client's central venous line is located in the right subclavian vein. The
nurse asks the client to take which essential action during the tubing change?
A. Breathe normally.
B. Turn the head to the right.
C. Exhale slowly and evenly.
D. Take a deep breath, hold it, and bear down.
Answer: D.
The client should be asked to perform the Valsalva maneuver during tubing
changes. This helps avoid air embolism during tubing changes. The nurse asks the
client to take a deep breath, hold it, and bear down. If the intravenous line is on
the right, the client turns his or her head to the left. This position increases
intrathoracic pressure. Breathing normally and exhaling slowly and evenly are
inappropriate and could enhance the potential for an air embolism during the
tubing change.
, The clinic nurse prepares to perform a focused assessment on a client who is
complaining of symptoms of a cold, a cough, and lung congestion. Which should
the nurse include for this type of assessment? Select all that apply.
1. Auscultating lung sounds
2. Obtaining client's temperature
3. Assessing the strength of peripheral pulses
4. Obtaining information about the client's respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or disease
Answers: 1, 2, 4
Rationale: A focused assessment focuses on a limited or short-term problem, such
as the client's complaint. Because the client is complaining of symptoms of a cold,
a cough, and lung congestion, the nurse would focus on the respiratory system
and the presence of an infection. A complete assessment includes a complete
health history and physical examination and forms a baseline database. Assessing
the strength of peripheral pulses relates to a vascular assessment, which is not
related to this client's complaints. A musculoskeletal and neurological examination
also is not related to this client's complaints. However, strength of peripheral
pulses and a musculoskeletal and neurological examination would be included in a
