NSG 252 Exam 3
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1. NCLEX Examination Challenge 38.2 Answer: C
Physiological Integrity Rationale: The gold stan-
A client was just admitted to the emergency depart- dard for most clients (un-
ment with a diagnosis of new-onset acute ischemic less there are contraindi-
stroke. What drug would the nurse anticipate to treat cations) is to administer
the client at this time? fibrinolytic therapy to dis-
A. Heparin solve the clot and pre-
B. Nimodipine vent long-term symptoms
C. Alteplase of the stroke. The only ap-
D. Aspirin proved fibrinolytic drug is
alteplase; therefore,Choice
C is the correct response.
Heparin or aspirin (Choic-
es A and D) may be used
after alteplase to prevent
further clot formation. Ni-
modipine (Choice B) is a
calcium channel blocker
2. NCLEX Examination Challenge 38.3 Answer: D
Health Promotion and Maintenance Rationale: All of these
The nurse is teaching a client who recently experi- statements are correct ex-
enced a mild traumatic brain injury about follow-up cept for Choice D. The
care at home. Which statement by the client indicates client should rest and
a need for further teaching? avoid strenuous activity for
A. "I can take acetaminophen every 4 hours as needed at least 48 hours af-
for headache." ter returning home to al-
B. "I should avoid taking any sedatives or alcohol for low healing to begin and
at least 24 hours." to provide time to mon-
C. "I should make an appointment for follow-up with itor the client for any
my primary health care provider." neurologic changes. Con-
struction work is probably
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D. "I can go back to work as a construction worker as strenuous and should be
soon as I get home." avoided
for at least 48 hours.
3. Mastery Questions Answer: C
1. The nurse is caring for a client receiving alteplase for Rationale: The client is al-
an acute ischemic stroke. What is the priority nursing ready receiving alteplase,
action for the client at this time? so calculating the amount
A. Position the client an upright sitting position. of drug to be given is
B. Monitor the client's heart rate frequently. not relevant at this time
C. Carefully observe for any indication of bleeding. (Choice D). The client's
D. Administer the drug based on the client's weigh vital signs are frequent-
ly monitored for signs of
severely increased blood
pressure, which can occur
when receiv-
ing this medication. Heart
rate is generally unaffect-
ed unless the client experi-
ences bleeding with hypo-
volemia. Therefore, Choice
B is incorrect. The head of
the bed should be elevat-
ed at a semi-Fowler's po-
sition, but not necessarily
in an upright sitting posi-
tion,
which could lower the
blood pressure more than
the desired level (Choice
A). Bleeding is a ma-
jor adverse effect of al-
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teplase; therefore, the pri-
ority for care is that the
nurse would monitor care-
fully for any signs of ex-
ternal or internal bleeding
(Choice C).
4. 2. The nurse is preparing to administer mannitol for Answer: B, C, D, E
a client who sustained a severe traumatic brain injury Rationale: Mannitol is a
this morning. Which of the following actions are appro- potent osmotic diuretic
priate for the nurse to take related to drug administra- used to reduce cerebral
tion? Select all that apply. edema. A filtered nee-
dle is needed to give the
A. Document urinary output every 4 to 8 hours. drug to remove crystal-
B. Use a filtered needle if giving the drug via IV push. loids (Choice B). The nurse
C. Monitor serum electrolyte levels daily. would observe for symp-
D. Monitor serum osmolality daily. toms of dehydration as the
E. Observe for symptoms of dehydration. client's urinary output in-
creases (Choice E). Serum
electrolytes and osmolal-
ity would be monitored
at least daily (Choices C
and D); however, urinary
output would be recorded
every hour, not every 4 to 8
hours (Choice
A). Therefore, Choice A is
the only incorrect choice
5. 3. The nurse is observing a client with a mild traumat- Answer: A
ic brain injury for changes in level of consciousness Rationale: Loss of reflex-
(LOC). Which of the following client findings indicates es and decorticate posi-
, NSG 252 Exam 3
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an early change in LOC? tioning are very late signs
of declining LOC (Choic-
A. Irritability es B and C). The earli-
B. Loss of reflexes est finding is a change in
C. Decorticate positioning behavior, such as irritabili-
D. Dizziness and vertigo ty and restlessness (Choice
A). Choice D is unrelated
to declining or changing
LOC.
6. NCLEX Examination Challenge 35.2 Answer: D
Physiological Integrity Rationale: The maximum
The nurse assesses a nonresponsive client using the score for the GCS tool is
Glasgow Coma Scale and determines the client's total 15, meaning that the client
score is 6. How would the nurse interpret this finding? is fully alert and orient-
A. The client is alert and awake. ed. This client is non re-
B. The client is drowsy and lethargic. sponsive with a score of
C. The client is stuporous. 6, so Choice A is incor-
D. The client is comatose. rect. Any total score below
7 indicates that the client
is in a coma; therefore,
Choice D is the correct re-
sponse. Choices B and C
are states of conscious-
ness that would render a
midrange score above 6.
7. Mastery Questions Answer: A
1. The nurse is caring for a client who recently had a Rationale: A decline in the
traumatic brain injury but has been alert and oriented client's level of conscious-
all day. Which of the following assessments would the ness is the most impor-
nurse carefully monitor to detect early changes in the tant and reliable early as-
Study online at https://quizlet.com/_i6hrwd
1. NCLEX Examination Challenge 38.2 Answer: C
Physiological Integrity Rationale: The gold stan-
A client was just admitted to the emergency depart- dard for most clients (un-
ment with a diagnosis of new-onset acute ischemic less there are contraindi-
stroke. What drug would the nurse anticipate to treat cations) is to administer
the client at this time? fibrinolytic therapy to dis-
A. Heparin solve the clot and pre-
B. Nimodipine vent long-term symptoms
C. Alteplase of the stroke. The only ap-
D. Aspirin proved fibrinolytic drug is
alteplase; therefore,Choice
C is the correct response.
Heparin or aspirin (Choic-
es A and D) may be used
after alteplase to prevent
further clot formation. Ni-
modipine (Choice B) is a
calcium channel blocker
2. NCLEX Examination Challenge 38.3 Answer: D
Health Promotion and Maintenance Rationale: All of these
The nurse is teaching a client who recently experi- statements are correct ex-
enced a mild traumatic brain injury about follow-up cept for Choice D. The
care at home. Which statement by the client indicates client should rest and
a need for further teaching? avoid strenuous activity for
A. "I can take acetaminophen every 4 hours as needed at least 48 hours af-
for headache." ter returning home to al-
B. "I should avoid taking any sedatives or alcohol for low healing to begin and
at least 24 hours." to provide time to mon-
C. "I should make an appointment for follow-up with itor the client for any
my primary health care provider." neurologic changes. Con-
struction work is probably
, NSG 252 Exam 3
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D. "I can go back to work as a construction worker as strenuous and should be
soon as I get home." avoided
for at least 48 hours.
3. Mastery Questions Answer: C
1. The nurse is caring for a client receiving alteplase for Rationale: The client is al-
an acute ischemic stroke. What is the priority nursing ready receiving alteplase,
action for the client at this time? so calculating the amount
A. Position the client an upright sitting position. of drug to be given is
B. Monitor the client's heart rate frequently. not relevant at this time
C. Carefully observe for any indication of bleeding. (Choice D). The client's
D. Administer the drug based on the client's weigh vital signs are frequent-
ly monitored for signs of
severely increased blood
pressure, which can occur
when receiv-
ing this medication. Heart
rate is generally unaffect-
ed unless the client experi-
ences bleeding with hypo-
volemia. Therefore, Choice
B is incorrect. The head of
the bed should be elevat-
ed at a semi-Fowler's po-
sition, but not necessarily
in an upright sitting posi-
tion,
which could lower the
blood pressure more than
the desired level (Choice
A). Bleeding is a ma-
jor adverse effect of al-
, NSG 252 Exam 3
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teplase; therefore, the pri-
ority for care is that the
nurse would monitor care-
fully for any signs of ex-
ternal or internal bleeding
(Choice C).
4. 2. The nurse is preparing to administer mannitol for Answer: B, C, D, E
a client who sustained a severe traumatic brain injury Rationale: Mannitol is a
this morning. Which of the following actions are appro- potent osmotic diuretic
priate for the nurse to take related to drug administra- used to reduce cerebral
tion? Select all that apply. edema. A filtered nee-
dle is needed to give the
A. Document urinary output every 4 to 8 hours. drug to remove crystal-
B. Use a filtered needle if giving the drug via IV push. loids (Choice B). The nurse
C. Monitor serum electrolyte levels daily. would observe for symp-
D. Monitor serum osmolality daily. toms of dehydration as the
E. Observe for symptoms of dehydration. client's urinary output in-
creases (Choice E). Serum
electrolytes and osmolal-
ity would be monitored
at least daily (Choices C
and D); however, urinary
output would be recorded
every hour, not every 4 to 8
hours (Choice
A). Therefore, Choice A is
the only incorrect choice
5. 3. The nurse is observing a client with a mild traumat- Answer: A
ic brain injury for changes in level of consciousness Rationale: Loss of reflex-
(LOC). Which of the following client findings indicates es and decorticate posi-
, NSG 252 Exam 3
Study online at https://quizlet.com/_i6hrwd
an early change in LOC? tioning are very late signs
of declining LOC (Choic-
A. Irritability es B and C). The earli-
B. Loss of reflexes est finding is a change in
C. Decorticate positioning behavior, such as irritabili-
D. Dizziness and vertigo ty and restlessness (Choice
A). Choice D is unrelated
to declining or changing
LOC.
6. NCLEX Examination Challenge 35.2 Answer: D
Physiological Integrity Rationale: The maximum
The nurse assesses a nonresponsive client using the score for the GCS tool is
Glasgow Coma Scale and determines the client's total 15, meaning that the client
score is 6. How would the nurse interpret this finding? is fully alert and orient-
A. The client is alert and awake. ed. This client is non re-
B. The client is drowsy and lethargic. sponsive with a score of
C. The client is stuporous. 6, so Choice A is incor-
D. The client is comatose. rect. Any total score below
7 indicates that the client
is in a coma; therefore,
Choice D is the correct re-
sponse. Choices B and C
are states of conscious-
ness that would render a
midrange score above 6.
7. Mastery Questions Answer: A
1. The nurse is caring for a client who recently had a Rationale: A decline in the
traumatic brain injury but has been alert and oriented client's level of conscious-
all day. Which of the following assessments would the ness is the most impor-
nurse carefully monitor to detect early changes in the tant and reliable early as-
