Nclex questions 4100 exam 3
The nurse is preparing to care for a client 4
who has returned to the nursing unit Rationale:
following cardiac catheterization performed After cardiac catheterization, the extremity into which
the through the femoral vessel. The nurse catheter was inserted is kept straight for 4 to 6
hours. The
checks the health care provider's (HCP's) client is maintained on bed rest for 4 to 6 hours (time
for bed prescription and plans to allow which client rest may vary depending on the HCP's
preference and on position or activity following the procedure? whether a vascular closure
device was used) and the client
may turn from side to side. The head is elevated no more
than 30 degrees (although some HCPs prefer a lower
position or
1. Bed rest in high Fowler's position the flat position) until
hemostasis is adequately achieved.
2.Bed rest with bathroom privileges only
3. Bed rest with head
elevation at 60 degrees
,The nurse is assessing the functioning 3, 4, 5, 6
of a chest tube drainage system in a Rationale:
client who has just returned from the The bubbling of water in the water seal chamber
recovery room following a thoracotomy indicates air drainage from the client and usually is seen
with wedge resection. Which are the when intrathoracic pressure is higher than atmospheric
expected pressure, and may occur during exhalation, coughing, or
assessment findings? Select all that apply. sneezing. Excessive bubbling in the water seal chamber
may indicate an air leak, an
unexpected finding. Fluctuation of water in the tube in the
1. Excessive bubbling in the water seal chamber during inhalation and exhalation is
water seal chamber expected. An absence of fluctuation may indicate that the
2.Vigorous bubbling in the suction chest tube is obstructed or that the lung has reexpanded
control chamber and that no more air is leaking into the pleural space.
3.Drainage system maintained below Gentle (not vigorous) bubbling should be noted in the
the client's chest suction control
4. 50 mL of drainage in the chamber. A total of 50 mL of drainage is not excessive in
drainage collection chamber a client returning to the nursing unit from the recovery
5. Occlusive dressing in place over the room.
chest tube insertion site Drainage that is more than 70 to 100 mL/hour is
6.Fluctuation of water in the tube in considered excessive and requires notification of the health
the water seal chamber during care provider.
inhalation and exhalation The chest tube insertion site is covered with an
occlusive (airtight) dressing to prevent air from
entering the pleural space. Positioning the drainage
system below the client's chest allows gravity to
drain the pleural space.
The nurse is assisting a health care 4
provider with the removal of a chest Rationale:
tube. The nurse should instruct the When the chest tube is removed, the client is asked to
client to take which action? perform the Valsalva maneuver (take a deep breath, exhale,
and bear down). The tube is quickly withdrawn, and an
1. Stay very still. airtight dressing is taped in place. An alternative
2.Exhale very quickly. instruction is to ask the client to take a deep breath and
3.Inhale and exhale quickly. hold the breath while the tube is removed.
4. Perform the Valsalva maneuver.
The nurse caring for a client with a 2
pneumothorax and who has had a Rationale:
chest tube inserted notes Fluctuation with inspiration and expiration, not continuous
continuous gentle bubbling, should be noted in the water seal chamber.
bubbling in the water seal chamber. What Intermittent bubbling may be noted if the client has a
action is most appropriate? known pneumothorax, but this should decrease as time
goes on and as the pneumothorax begins to resolve.
Therefore, the nurse should check for an air leak. If a wet
1. Do nothing, because this is an chest drainage system is used, bubbling would be
expected finding. continuous in the suction control
2.Check for an air leak, because chamber and not intermittent. In a dry system, there is no
the bubbling should be bubbling. Increasing the suction pressure only increases
intermittent. the rate of evaporation of water in the drainage system;
3. Increase the suction pressure so that in addition, increasing the suction can be harmful and is
the bubbling becomes vigorous. not done without a specific prescription to do so if using
4.Clamp the chest tube and notify a wet system. Dry systems will allow for only a certain
the health care provider amount of suction to be applied; an orange bellow will
immediately. appear in the suction window, indicating that the proper
amount of suction has been applied. Chest tubes should be
clamped only with a health care provider's prescription.
,The nurse is caring for a client with lung 1, 3, 6
cancer and bone metastasis. What signs and Rationale:
symptoms would the nurse recognize as Oncological emergencies include sepsis, disseminated
indications of a possible intravascular coagulation, syndrome of inappropriate
oncological emergency? Select all antidiuretic hormone, spinal cord compression,
that apply. hypercalcemia, superior vena cava syndrome, and tumor
lysis syndrome. Blockage of blood flow to the venous
system of the head resulting in facial edema is a sign of
1. Facial edema in the morning superior vena
2. Weight loss of 20 lb (9 kg) in 1 cava syndrome. A serum calcium level of 12 mg/dL (3.0
month mmol/L) indicates hypercalcemia. Numbness and tingling of
3. Serum calcium level of 12 mg/dL the lower extremities could be a sign of spinal cord
(3.0 mmol/L) compression. Mild hypokalemia and weight loss are not
4. Serum sodium level of 136 mg/dL oncological emergencies. A sodium level of 136 mg/dL (136
(136 mmol/L) mmol/L) is a normal level.
5. Serum potassium level of 3.4 mg/dL
(3.4 mmol/L)
6. Numbness and tingling of the
lower extremities
The nurse is assessing the respiratory 4
status of a client who has suffered a Rationale:
fractured rib. Rib fractures result from a blunt injury or a fall. Typical
The nurse should expect to note which signs and symptoms include pain and tenderness
finding? localized at the fracture site that is exacerbated by
inspiration and palpation, shallow respirations, splinting
or guarding the chest
1. Slow, deep respirations protectively to minimize chest movement, and possible
2.Rapid, deep respirations bruising at the fracture site. Paradoxical respirations are
3.Paradoxical respirations seen with flail chest
4. Pain, especially with inspiration
A client with a chest injury has suffered 3
flail chest. The nurse assesses the client
for which most distinctive sign of flail Flail chest results from multiple rib fractures. This results
chest? in a
"floating" section of ribs. Because this section is unattached
to the rest of the bony rib cage, this segment results in
1. Cyanosis paradoxical chest movement. This means that the force of
2. Hypotension inspiration pulls the fractured segment inward, while the
3.Paradoxical chest movement rest of the chest expands. Similarly, during exhalation, the
4. Dyspnea, especially on exhalation segment balloons outward while the rest of the chest
moves inward.
This is a characteristic sign of flail chest.
The nurse is assessing a client with 4
multiple trauma who is at risk for
developing acute respiratory distress The earliest detectable sign of acute respiratory
syndrome. The nurse distress syndrome is an increased respiratory rate,
should assess for which earliest sign of which can begin from 1 to 96 hours after the initial
acute respiratory distress syndrome? insult to the body. This is followed by increasing
dyspnea, air hunger, retraction of
accessory muscles, and cyanosis. Breath sounds may be
1. Bilateral wheezing clear or consist of fine inspiratory crackles or diffuse
2.Inspiratory crackles coarse
3. Intercostal retractions crackles.
4. Increased respiratory rate
, A client has experienced pulmonary 3
embolism. The nurse should assess for
which symptom, which is most commonly The most common initial symptom in pulmonary embolism is
reported? chest pain that is sudden in onset. The next most
commonly reported symptom is dyspnea, which is
accompanied by an increased respiratory rate. Other
1. Hot, flushed feeling typical symptoms of
2.Sudden chills and fever pulmonary embolism include apprehension and restlessness,
3.Chest pain that occurs suddenly tachycardia, cough, and cyanosis.
4. Dyspnea when deep breaths are taken
A client in sinus bradycardia, with a heart 4. Prepare for transcutaneous pacing.
rate of 45 beats/minute, complains of Rationale:
dizziness and has a blood pressure of Sinus bradycardia is noted with a heart rate less than 60
82/60 mm Hg. Which prescription should beats per minute. This rhythm becomes a concern when
the nurse anticipate will be prescribed? the client becomes symptomatic. Hypotension and
dizziness are signs of decreased cardiac output.
Transcutaneous pacing provides a temporary measure to
1. Administer digoxin. increase the heart rate and thus perfusion in the
2.Defibrillate the client. symptomatic client. Defibrillation is used for
3.Continue to monitor the client. treatment of pulseless ventricular tachycardia and ventricular
4. Prepare for transcutaneous pacing fibrillation. Digoxin will further decrease the client's heart
rate.
Continuing to monitor the client delays necessary
intervention.
The nurse in a medical unit is caring for a 1, 2, 3, 4
client with heart failure. The client
suddenly develops extreme dyspnea, Rationale:
tachycardia,
and lung crackles and the nurse Pulmonary edema is a life-threatening event that can result
suspects pulmonary edema. The nurse from severe heart failure. In pulmonary edema, the left
immediately asks another nurse to ventricle fails to eject sufficient blood, and pressure
contact the health care provider and increases in the lungs because of the accumulated
prepares to implement blood. Oxygen is
which priority interventions? Select all that always prescribed, and the client is placed in a high
apply. Fowler's position to ease the work of breathing.
Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. A Foley
1. Administering oxygen catheter is inserted to measure output accurately.
2.Inserting a Foley catheter Intravenously administered morphine sulfate reduces
3.Administering furosemide venous return (preload), decreases anxiety, and also
4.Administering morphine reduces the work of breathing. Transporting the client to
sulfate intravenously the coronary care unit is not a priority intervention. In fact,
5.Transporting the client to the this may not be necessary at all if the client's response
coronary care unit to treatment is successful.
6. Placing the client in a low Fowler's
side-lying position Test-Taking Strategy:
Note the strategic words priority interventions and focus
on the client's diagnosis. Recall the pathophysiology
associated with pulmonary edema and use the ABCs—
airway, breathing, and circulation—to help determine
priority interventions.
Review priority interventions for the client with
pulmonary edema if you had difficulty with this
question.
The nurse is preparing to care for a client 4
who has returned to the nursing unit Rationale:
following cardiac catheterization performed After cardiac catheterization, the extremity into which
the through the femoral vessel. The nurse catheter was inserted is kept straight for 4 to 6
hours. The
checks the health care provider's (HCP's) client is maintained on bed rest for 4 to 6 hours (time
for bed prescription and plans to allow which client rest may vary depending on the HCP's
preference and on position or activity following the procedure? whether a vascular closure
device was used) and the client
may turn from side to side. The head is elevated no more
than 30 degrees (although some HCPs prefer a lower
position or
1. Bed rest in high Fowler's position the flat position) until
hemostasis is adequately achieved.
2.Bed rest with bathroom privileges only
3. Bed rest with head
elevation at 60 degrees
,The nurse is assessing the functioning 3, 4, 5, 6
of a chest tube drainage system in a Rationale:
client who has just returned from the The bubbling of water in the water seal chamber
recovery room following a thoracotomy indicates air drainage from the client and usually is seen
with wedge resection. Which are the when intrathoracic pressure is higher than atmospheric
expected pressure, and may occur during exhalation, coughing, or
assessment findings? Select all that apply. sneezing. Excessive bubbling in the water seal chamber
may indicate an air leak, an
unexpected finding. Fluctuation of water in the tube in the
1. Excessive bubbling in the water seal chamber during inhalation and exhalation is
water seal chamber expected. An absence of fluctuation may indicate that the
2.Vigorous bubbling in the suction chest tube is obstructed or that the lung has reexpanded
control chamber and that no more air is leaking into the pleural space.
3.Drainage system maintained below Gentle (not vigorous) bubbling should be noted in the
the client's chest suction control
4. 50 mL of drainage in the chamber. A total of 50 mL of drainage is not excessive in
drainage collection chamber a client returning to the nursing unit from the recovery
5. Occlusive dressing in place over the room.
chest tube insertion site Drainage that is more than 70 to 100 mL/hour is
6.Fluctuation of water in the tube in considered excessive and requires notification of the health
the water seal chamber during care provider.
inhalation and exhalation The chest tube insertion site is covered with an
occlusive (airtight) dressing to prevent air from
entering the pleural space. Positioning the drainage
system below the client's chest allows gravity to
drain the pleural space.
The nurse is assisting a health care 4
provider with the removal of a chest Rationale:
tube. The nurse should instruct the When the chest tube is removed, the client is asked to
client to take which action? perform the Valsalva maneuver (take a deep breath, exhale,
and bear down). The tube is quickly withdrawn, and an
1. Stay very still. airtight dressing is taped in place. An alternative
2.Exhale very quickly. instruction is to ask the client to take a deep breath and
3.Inhale and exhale quickly. hold the breath while the tube is removed.
4. Perform the Valsalva maneuver.
The nurse caring for a client with a 2
pneumothorax and who has had a Rationale:
chest tube inserted notes Fluctuation with inspiration and expiration, not continuous
continuous gentle bubbling, should be noted in the water seal chamber.
bubbling in the water seal chamber. What Intermittent bubbling may be noted if the client has a
action is most appropriate? known pneumothorax, but this should decrease as time
goes on and as the pneumothorax begins to resolve.
Therefore, the nurse should check for an air leak. If a wet
1. Do nothing, because this is an chest drainage system is used, bubbling would be
expected finding. continuous in the suction control
2.Check for an air leak, because chamber and not intermittent. In a dry system, there is no
the bubbling should be bubbling. Increasing the suction pressure only increases
intermittent. the rate of evaporation of water in the drainage system;
3. Increase the suction pressure so that in addition, increasing the suction can be harmful and is
the bubbling becomes vigorous. not done without a specific prescription to do so if using
4.Clamp the chest tube and notify a wet system. Dry systems will allow for only a certain
the health care provider amount of suction to be applied; an orange bellow will
immediately. appear in the suction window, indicating that the proper
amount of suction has been applied. Chest tubes should be
clamped only with a health care provider's prescription.
,The nurse is caring for a client with lung 1, 3, 6
cancer and bone metastasis. What signs and Rationale:
symptoms would the nurse recognize as Oncological emergencies include sepsis, disseminated
indications of a possible intravascular coagulation, syndrome of inappropriate
oncological emergency? Select all antidiuretic hormone, spinal cord compression,
that apply. hypercalcemia, superior vena cava syndrome, and tumor
lysis syndrome. Blockage of blood flow to the venous
system of the head resulting in facial edema is a sign of
1. Facial edema in the morning superior vena
2. Weight loss of 20 lb (9 kg) in 1 cava syndrome. A serum calcium level of 12 mg/dL (3.0
month mmol/L) indicates hypercalcemia. Numbness and tingling of
3. Serum calcium level of 12 mg/dL the lower extremities could be a sign of spinal cord
(3.0 mmol/L) compression. Mild hypokalemia and weight loss are not
4. Serum sodium level of 136 mg/dL oncological emergencies. A sodium level of 136 mg/dL (136
(136 mmol/L) mmol/L) is a normal level.
5. Serum potassium level of 3.4 mg/dL
(3.4 mmol/L)
6. Numbness and tingling of the
lower extremities
The nurse is assessing the respiratory 4
status of a client who has suffered a Rationale:
fractured rib. Rib fractures result from a blunt injury or a fall. Typical
The nurse should expect to note which signs and symptoms include pain and tenderness
finding? localized at the fracture site that is exacerbated by
inspiration and palpation, shallow respirations, splinting
or guarding the chest
1. Slow, deep respirations protectively to minimize chest movement, and possible
2.Rapid, deep respirations bruising at the fracture site. Paradoxical respirations are
3.Paradoxical respirations seen with flail chest
4. Pain, especially with inspiration
A client with a chest injury has suffered 3
flail chest. The nurse assesses the client
for which most distinctive sign of flail Flail chest results from multiple rib fractures. This results
chest? in a
"floating" section of ribs. Because this section is unattached
to the rest of the bony rib cage, this segment results in
1. Cyanosis paradoxical chest movement. This means that the force of
2. Hypotension inspiration pulls the fractured segment inward, while the
3.Paradoxical chest movement rest of the chest expands. Similarly, during exhalation, the
4. Dyspnea, especially on exhalation segment balloons outward while the rest of the chest
moves inward.
This is a characteristic sign of flail chest.
The nurse is assessing a client with 4
multiple trauma who is at risk for
developing acute respiratory distress The earliest detectable sign of acute respiratory
syndrome. The nurse distress syndrome is an increased respiratory rate,
should assess for which earliest sign of which can begin from 1 to 96 hours after the initial
acute respiratory distress syndrome? insult to the body. This is followed by increasing
dyspnea, air hunger, retraction of
accessory muscles, and cyanosis. Breath sounds may be
1. Bilateral wheezing clear or consist of fine inspiratory crackles or diffuse
2.Inspiratory crackles coarse
3. Intercostal retractions crackles.
4. Increased respiratory rate
, A client has experienced pulmonary 3
embolism. The nurse should assess for
which symptom, which is most commonly The most common initial symptom in pulmonary embolism is
reported? chest pain that is sudden in onset. The next most
commonly reported symptom is dyspnea, which is
accompanied by an increased respiratory rate. Other
1. Hot, flushed feeling typical symptoms of
2.Sudden chills and fever pulmonary embolism include apprehension and restlessness,
3.Chest pain that occurs suddenly tachycardia, cough, and cyanosis.
4. Dyspnea when deep breaths are taken
A client in sinus bradycardia, with a heart 4. Prepare for transcutaneous pacing.
rate of 45 beats/minute, complains of Rationale:
dizziness and has a blood pressure of Sinus bradycardia is noted with a heart rate less than 60
82/60 mm Hg. Which prescription should beats per minute. This rhythm becomes a concern when
the nurse anticipate will be prescribed? the client becomes symptomatic. Hypotension and
dizziness are signs of decreased cardiac output.
Transcutaneous pacing provides a temporary measure to
1. Administer digoxin. increase the heart rate and thus perfusion in the
2.Defibrillate the client. symptomatic client. Defibrillation is used for
3.Continue to monitor the client. treatment of pulseless ventricular tachycardia and ventricular
4. Prepare for transcutaneous pacing fibrillation. Digoxin will further decrease the client's heart
rate.
Continuing to monitor the client delays necessary
intervention.
The nurse in a medical unit is caring for a 1, 2, 3, 4
client with heart failure. The client
suddenly develops extreme dyspnea, Rationale:
tachycardia,
and lung crackles and the nurse Pulmonary edema is a life-threatening event that can result
suspects pulmonary edema. The nurse from severe heart failure. In pulmonary edema, the left
immediately asks another nurse to ventricle fails to eject sufficient blood, and pressure
contact the health care provider and increases in the lungs because of the accumulated
prepares to implement blood. Oxygen is
which priority interventions? Select all that always prescribed, and the client is placed in a high
apply. Fowler's position to ease the work of breathing.
Furosemide, a rapid-acting diuretic, will eliminate
accumulated fluid. A Foley
1. Administering oxygen catheter is inserted to measure output accurately.
2.Inserting a Foley catheter Intravenously administered morphine sulfate reduces
3.Administering furosemide venous return (preload), decreases anxiety, and also
4.Administering morphine reduces the work of breathing. Transporting the client to
sulfate intravenously the coronary care unit is not a priority intervention. In fact,
5.Transporting the client to the this may not be necessary at all if the client's response
coronary care unit to treatment is successful.
6. Placing the client in a low Fowler's
side-lying position Test-Taking Strategy:
Note the strategic words priority interventions and focus
on the client's diagnosis. Recall the pathophysiology
associated with pulmonary edema and use the ABCs—
airway, breathing, and circulation—to help determine
priority interventions.
Review priority interventions for the client with
pulmonary edema if you had difficulty with this
question.
