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.