NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023

NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023 Physiological Integrity: Reduction of Risk Potential Questions 1. You measure your 2 year old client’s vital signs as:  Respiratory rate: 32 breaths per minute  Pulse: 110 beats per minute  Blood pressure: 55/82 The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating: A. “The respiratory rate is a little too fast but the other vital signs are normal.” B. “The pulse rate is a little too fast but the other vital signs are normal.” C. “The blood pressure is a little low but the other vital signs are normal.” D. “All of these vital signs are normal for a child that is 2 years of age.” Correct Response: D All of these vital signs are normal for the toddler who is 2 years old. The normal vital signs for the toddler are:  Respiratory rate: From 20 to 40 per minute  Pulse rate: From 90 to 140 beats per minute  Blood pressure: Diastolic from 50 to 80 mm Hg and systolic from 80 to 112 mm Hg 2. You measure your 5 year old client’s vital signs as:  Respiratory rate: 32 breaths per minute  Pulse: 100 beats per minute  Blood pressure: 85/55 The mother asks you if these vital signs are normal. You should respond to this mother’s question by stating: A. “The respiratory rate is a little too fast but the other vital signs are normal.” B. “The pulse rate is a little too fast but the other vital signs are normal.” C. “The blood pressure is a little low but the other vital signs are normal.” D. “All of these vital signs are normal for a child that is 2 years of age.” Correct Response: A The respiratory rate is a little too fast for this 5 year old preschool client. The normal respiratory rate for this client should be from 22 to 30 per minute. The normal pulse rate and blood pressure for the preschool child are from 80 to 110 beats per minute and a diastolic from 50 to 78 mm Hg and a systolic from 82 to 110 mm Hg. 3. Which of the following data points about your client’s hemodynamic values would you report to the doctor as abnormal? A. Pulmonary Artery Systolic Pressure: 22 mm Hg B. Pulmonary Artery Wedge Pressure: 22 mm Hg C. Pulmonary Artery Diastolic Pressure: 10 mm Hg D. Central Venous Pressure: 5 mm Hg Correct Response: B You would report the pulmonary artery wedge pressure of 22 mm Hg because the normal pulmonary artery wedge pressure is from 4 to 12 mm Hg. The other normal hemodynamic values are:  Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg  Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg  Central Venous Pressure: 1 to 8 mm Hg 4. The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen? A. The need to cleanse the perineal area with circular wipes. B. The need to cleanse the perineal area from the “dirtiest” to the “cleanest”. C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia. D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia. Correct Response: C You would instruct your female client to use a new antiseptic wipe for each wipe from the inner to the outer labia. A principle of asepsis is the cleansing of areas from the cleanest to the dirtiest and NOT the reverse; therefore, the inner labia are cleansed before the outer labia. The female perineal area is prepped with straight strokes and wipes; and the male wipes with a circular pattern around the urinary meatus. 5. Select the step of blood glucose level monitoring that is NOT accurate. A. Turn the finger down so the blood will drop with gravity. B. Wipe off the first drop of blood using sterile gauze. C. Prick the side of the finger using the lancet. D. Prick the pad of the finger using the lancet. Correct Response: D Pricking the pad of the finger using the lancet is NOT a step in the procedure for obtaining a blood glucose sample for testing. Instead, the side of the finger is pricked with the lancet. The procedure for checking the client’s blood glucose levels in correct sequential order is as follows:  Verify and confirm that the code strip corresponds to the meter code.  Disinfect the client’s finger with an alcohol swab.  Prick the side of the finger using the lancet.  Turn the finger down so the blood will drop with gravity.  Wipe off the first drop of blood using sterile gauze.  Collect the next drop on the test strip.  Hold the gauze on the client’s finger after the specimen has been obtained.  Read the client’s blood glucose level on the monitor. 6. Select the arterial blood gas that you would report to the client’s physician because it is not within normal parameters and it is also a significant change for the client. A. PaO2: 65 mm Hg B. PaCO2: 40 mm Hg C. Arterial blood pH: 7.39 D. SaO2: 96% Correct Response: A You would report the client’s PaO2 of 65 mm Hg because it is not within normal parameters and it is also a significant change for the client. The normal partial pressure of oxygen (PaO2) is from 75 to 100 mm Hg. The other blood gases, above, are within normal limits, as follows:  Partial pressure of carbon dioxide (PaCO2): 38 - 42 mmHg  Arterial blood pH: 7.38 - 7.42  Oxygen saturation (SaO2): 94 - 100% 7. Which lipid level would you report to the doctor because it is not normal and it is also a significant change in the client? A. Triglycerides: 75 mg/dL B. Total cholesterol: 6.5 mmol/L C. High-density lipoprotein (HDL): 60 mg/dL D. Low-density lipoprotein (LDL): 955 mg/dL Correct Response: B You would report a total cholesterol level of 6.5 mmol/L because this value exceeds the high normal for total cholesterol which is 5.5 mmol/L and the normal range is from 3 to 5.5 mmol/L. The other lipid levels are normal as follows:  Triglycerides: 50-150 mg/dL  High-density lipoprotein (HDL): 40-80 mg/dL  Low-density lipoprotein (LDL): 85-125 mg/dL 8. Which laboratory value would you report to the doctor because it is not normal and it is also a significant change in the client? A. Albumin: 40 g/L B. Amylase: 40 U/L C. Direct bilirubin: 17 μmol/L D. Total bilirubin: 17 μmol/L Correct Response: C You would report a direct bilirubin level of 17 μmol/L because this value exceeds the high normal for direct bilirubin which is 6 μmol/L and the normal range is from 0-6 μmol/L. The other gastrointestinal related normal laboratory values are as follows:  Albumin: 35-50 g/L  Amylase: 30-125 U/L  Total bilirubin: 2-20 μmol/L 9. Select the client who is at greatest risk for impaired vascular perfusion. A. A 76 year old female client who has a history of alcohol abuse. B. A 76 year old female client who has a history of radon gas exposure. C. A 64 year old male client who has a history of cigarette smoking. D. A 64 year old male client who has hypotension. Correct Response: D A 64 year old male client who has hypotension is at greatest risk for impaired vascular perfusion. Other risk factors associated with impaired vascular and tissue perfusion are:  Hypervolemia  Hypovolemia  Low hemoglobin  An immobilized limb  Hypoxia  Decreased cardiac output  Diabetes  Impaired oxygen transportation  Hypoventilation Alcohol abuse, cigarette smoking and exposures to radon place people at risk for cancer, rather than impaired perfusion. 10. Select the client who is at greatest risk for the development of cancer. A. A 76 year old female client who has a history of alcohol abuse. B. A 76 year old female client who has a history of diabetes. C. A 64 year old male client who has a history of impaired oxygen transport. D. A 64 year old male client who has hypotension. Correct Response: A The client who is at greatest risk for the development of cancer is the 76 year old female client who has a history of alcohol abuse. Data indicates that alcohol abuse can lead to cancer of the liver and other cancers. Diabetes, a history of impaired oxygen transport and hypotension are risk factors associated with poor tissue perfusion, and not cancer. 11. The Norton Scale measures: A. The level of pain among school age children. B. The risk for the impairment of skin integrity. C. Levels of muscular strength. D. Levels of mobility. Correct Response: B The Norton Scale measures the client’s risk for the impairment of skin integrity. The Norton Scale and the Braden Scale are standardized tools to screen clients for their risk of skin breakdown, pressure ulcers and an impairment of skin integrity. Pain levels among school age children are measured with other standardized pain tools for pediatric clients; and levels of muscular strength and mobility are measured also with other standardized tests and not the Norton Scale. 12. Which is an intrinsic risk factor that places the client at risk for pressure ulcers? A. Pressure B. Shearing C. Impaired tissue perfusion D. Friction Correct Response: C Impaired tissue perfusion is an intrinsic, or internal, risk factor that places the client at risk for pressure ulcers. Pressure, shearing and friction are extrinsic, or external, risk factors that places the client at risk for pressure impaired tissue perfusion. Other intrinsic risk factors associated with skin breakdown include:  Poor nutritional status  Immobility  A decreased level of consciousness including that which occurs with sedating medications  Fecal and/or urinary incontinence  Impaired circulation  Alterations in terms of the fluid balance  Altered neurological sensory functioning  Changes in terms of skin turgor  Boney prominences 13. Your client has a cuffed tracheostomy tube that now needs suctioning. You prepare and pre oxygenate the client and you have lubricated the tip of the suction catheter with a water soluble jelly. As you insert the suction catheter you reach a point of resistance. What should you do first? A. Inflate the cuff if the cuff is deflated. B. Deflate the cuff if the cuff is inflated. C. Remove the inner cannula of the tube. D. Call the doctor about this airway obstruction. Correct Response: B The first thing that you should do when you insert the suction catheter and you reach a point of resistance is to deflate the cuff when it is inflated and the second thing that you should do is to remove the inner cannula and suction out the mucous plug. You would not call the doctor because there is an airway obstruction; you should correct this problem with the measures above. 14. You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client? A. Maintain the client with NPO status for at least 4 hours prior to this procedure. B. Teach the client about the fact that they may experience muscle flaccidity. C. Teach the client about the fact that they may have a headache after the ECT. D. Maintain the client on continuous hemodynamic monitoring after the ECT. Correct Response: C You would teach the client about the fact that they may have a headache after the ECT. Other components of the teaching about the aftermath of the procedure that the client should know about include the fact that the client may have muscle soreness, not muscle flaccidity, confusion, amnesia and hypertension. The client should be maintained as NPO for at least 6 hours before ECT; and it is not necessary to maintain the client on continuous hemodynamic monitoring after the ECT, however, the client’s vital signs should be monitored. 15. Which neurological complication can occur when a vest restraint is too tight around the client’s body? A. Strnagulation B. Skin breakdown C. Skin pallor D. Numbness Correct Response: D The neurological complication can occur when a vest restraint is too tight around the client’s body is numbness and tingling that, unless corrected, can lead to neurological damage. Strangulation, skin breakdown and skin pallor can also occur when a restraint is too tight, however, these restraint complications are respiratory, integumentary system and circulatory system complications rather than neurological complications. 16. Which is a sign of thrombocytopenia? A. The appearance of petechiae B. Aplastic anemia C. The appearance of thrombophlebitis D. Elevated platelets Correct Response: A The appearance of petechiae is a sign of thrombocytopenia which is a low platelet count. Other signs and symptoms include purpura, easy bruising, epistaxis, and spontaneous hemorrhage and bleeding. Thrombocytopenia can occur as the result of several disorders and therapeutic treatments and interventions including aplastic anemia, HIV infection, a genetic disorder, cancer, particularly cancer that affects the bones, some viral pathogens like those that cause mononucleosis, as well as from therapeutic radiation therapy, chemotherapy and some medications such as Depakote. 17. You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post- operative period of time? A. Infection B. Pneumothorax C. Aspiration D. Dyspnea Correct Response: B The complication that you should be aware of during the immediate post-operative period of time after a thoracentesis is a pneumothorax. The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness of breath and pain. The treatment of a pneumothorax includes the correction of the underlying cause whenever possible and the placement of a chest tube to remove the blood and/or air in the pleural space which will re-expand the affected lung and recreate the negative pressure of the pleural space. Infection would not be evident during the immediate post-operative period; and, aspiration is not a complication of a thoracentesis. 18. During your system specific assessment of your client’s peripheral pulses, you note that the client’s posterior tibia pulse is weak and thready. You would document this finding as: A. The client’s posterior tibia pulse is Grade B B. The client’s posterior tibia pulse is Grade C C. The client’s posterior tibia pulse is 1 D. The client’s posterior tibia pulse is 2 Correct Response: C You would document this finding as “The client’s posterior tibia pulse is 1”. The strength, volume and fullness of the peripheral pulses are categorized and documented as follows:  0: Absent pulses  1: Weak pulse  2: Normal pulse  3: Increased volume  4: A bounding pulse Grades and grading are not used in reference to pulses. 19. Which tool or scale would you use for a focused neurological assessment of your client? A. The Lazarus Cognitive Appraisal Scale B. The Hamilton Rating Scale C. The McGill Scale D. The Rancho Los Amigos Scale Correct Response: D The tool or scale that you would use for a focused neurological assessment of your client is the Rancho Los Amigos Scale. Levels of consciousness, which is part of a complete focused neurological assessment, can be determined and measured by using the standardized Glasgow Coma Scale for adults and children or the Rancho Los Amigos Scale. The Rancho Los Amigos Scale determines the patient’s level of awareness and functioning which can range from a 1 to an 8 when a 1 is the complete lack of all responsiveness to all stimulation and an 8 is when a patient is fully alert, oriented, appropriate and purposeful. The McGill Pain Assessment is used to assess pain levels; the Lazarus Cognitive Appraisal Scale is used to assess levels of stress and coping; and the Hamilton Rating Scale is used to measure and assess depression. 20. You are the nurse in an ambulatory surgical center. Which of the following risk factors are associated with impaired and delayed healing? A. A lack of zinc B. A lack of vitamin E C. High iron levels D. High phosphorous levels Correct Response: A A lack of zinc, copper, iron and vitamins C and A are risks associated with impaired and delayed wound healing. Other risk factors that impede wound healing are:  Advancing age  Nutritional status  Some poor lifestyle choices  Some medications  Some diseases and disorders 21. As a nurse preceptor, you are in the operating room with a student nurse. The client has received general anesthesia. The student nurse says, “Oh no, the general anesthesia is not working. The client is shaking and moving.” How should you respond to this student nurse? A. “The client is having anesthesia awareness which is not good.” B. “This often happens during stage 2 of general anesthesia.” C. "The client needs more general anesthesia.” D. “The client is having a seizure.” Correct Response: B You should respond to this student nurse by stating, “This often happens during stage 2 of general anesthesia.” Stage 2 of general anesthesia, often referred to as the Excitement Stage, is characterized with uncontrollable muscular activity, irregular respirations, an irregular cardiac rhythm, and, at times, vomiting. This stage does not indicate the need for more general anesthesia. Anesthesia awareness, which is a rare complication of general anesthesia, is the lack of amnesia during surgery when the client remembers events during surgery and, at times, they remember the pain. Lastly, there is no evidence in this question that the client is having a seizure. 22. Which of the following is NOT a procedure to reduce risks associated with invasive surgeries? A. Surgical site marking B. A time out C. Medication reconciliation D. A neutral zone for sharps Correct Response: C Medication reconciliation prevents medication errors and other complications associated with medications and not a way to reduce surgical risks. Surgical marking, time outs that are done after surgical site marking is done, and a neutral zone for sharps do reduce surgical risks such as wrong site surgery, wrong patient surgeries and sharps injuries.