Saunders NCLEX Questions
A client admitted to the nursing unit from the hospital emergency department has a
C4 spinal cord injury. In conducting the admission assessment, what is the nurse's
priority action?
1.
Take the temperature.
2.
Listen to breath sounds.
3.
Observe dyskinesias.
4.
Assess extremity muscle strength. - ANS-2
Because compromise of respiration is a leading cause of death in cervical cord
injury, respiratory assessment is the highest priority. Assessment of temperature and
strength can be done after adequate oxygenation is ensured. Because dyskinesias
occur in cerebellar disorders, this is not as important a concern as in cord-injured
clients unless head injury is suspected.
\A client arrives in the hospital emergency department with a closed head injury to
the right side of the head caused by an assault with a baseball bat. The nurse
assesses the client neurologically, looking primarily for motor response deficits that
involve which area?
1.
The left side of the body
2.
The right side of the body
3.
Both sides of the body equally
4.
Cranial nerves only, such as speech and pupillary response - ANS-1
Motor responses such as weakness and decreased movement will be seen on the
side of the body that is opposite an area of head injury. Contralateral deficits result
,from compression of the cortex of the brain or the pyramidal tracts. Depending on
the severity of the injury, the client may have a variety of neurological deficits.
\A client being mechanically ventilated after experiencing a fat embolism is visibly
anxious. What is the best nursing action?
1.
Ask a family member to stay with the client at all times.
2.
Ask the health care provider for a prescription for succinylcholine.
3.
Encourage the client to sleep until arterial blood gas results improve.
4.
Provide reassurance to the client and give small doses of morphine sulfate
intravenously as prescribed. - ANS-4
Morphine sulfate often is prescribed for pain and anxiety in the client receiving
mechanical ventilation. The nurse should speak to the client calmly and provide
reassurance to the anxious client. Family members also are stressed, not just
because of the complication but because of the original injury. It is not beneficial to
ask the family to take on the burden of remaining with the client at all times.
Succinylcholine is a neuromuscular blocker but has no antianxiety properties.
Encouraging the client to sleep until arterial blood gas results improve does nothing
to reassure or help the client.
\A client had a seizure 1 hour ago. Family members were present during the episode
and reported that the client's jaw was moving as though grinding food. In helping to
determine the origin of this seizure, what should the nurse include in the client's
assessment?
1.
Presence of diaphoresis
2.
Loss of consciousness
3.
History of prior trauma
4.
Rotating eye movements - ANS-3
,Seizures that originate with specific motor phenomena are considered focal and are
indicative of a focal structural lesion in the brain, often caused by trauma, infection,
or drug consumption. Options 1, 2, and 4 address signs, rather than an origin of the
seizure.
\A client has a chest tube attached to a water seal drainage system. As part of
routine nursing care, the nurse should ensure that which intervention is
implemented?
1.
The water seal chamber has continuous bubbling, and assessment for crepitus is
done once a shift.
2.
The amount of drainage into the chest tube is noted and recorded every 24 hours in
the client's record.
3.
The suction control chamber has sterile water added every shift, and the system is
kept below waist level.
4.
The connection between the chest tube and the drainage system is taped, and an
occlusive dressing is maintained at the insertion site. - ANS-4
The nurse ensures that all system connections are securely taped to prevent
accidental disconnection and that an occlusive dressing is maintained at the chest
tube insertion site. Continuous bubbling in the water seal chamber indicates an air
leak in the system and requires immediate investigation and correction. Drainage is
noted and recorded every hour during the first 24 hours after insertion and every 8
hours thereafter. The system is kept below the level of the waist. Assessment for
crepitus is done once every 8 hours. Sterile water is added to the suction control
chamber only as needed to replace evaporation losses.
\A client has been admitted to the hospital with a diagnosis of acute pancreatitis and
the nurse is assessing the client's pain. What type of pain is consistent with this
diagnosis?
1.
Burning and aching, located in the left lower quadrant and radiating to the hip
2.
Severe and unrelenting, located in the epigastric area and radiating to the back
3.
Burning and aching, located in the epigastric area and radiating to the umbilicus
, 4.
Severe and unrelenting, located in the left lower quadrant and radiating to the groin -
ANS-2
The pain associated with acute pancreatitis is often severe and unrelenting, is
located in the epigastric region, and radiates to the back. The other options are
incorrect.
\A client has been admitted with chest trauma after a motor vehicle crash and has
undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has absence
of breath sounds in the right upper lobe of the lung. The nurse immediately assesses
for other signs of which condition?
1.
Right pneumothorax
2.
Pulmonary embolism
3.
Displaced endotracheal tube
4.
Acute respiratory distress syndrome - ANS-1
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds
on the affected side. Pneumothorax can cause increased airway pressure because
of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that
is inserted too far can cause absent breath sounds, but the lack of breath sounds
most likely would be on the left side because of the degree of curvature of the right
and left mainstem bronchi.
\A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present?
1.
Fluid is clear and tests negative for glucose.
2.
Fluid is grossly bloody in appearance and has a pH of 6.
3.
A client admitted to the nursing unit from the hospital emergency department has a
C4 spinal cord injury. In conducting the admission assessment, what is the nurse's
priority action?
1.
Take the temperature.
2.
Listen to breath sounds.
3.
Observe dyskinesias.
4.
Assess extremity muscle strength. - ANS-2
Because compromise of respiration is a leading cause of death in cervical cord
injury, respiratory assessment is the highest priority. Assessment of temperature and
strength can be done after adequate oxygenation is ensured. Because dyskinesias
occur in cerebellar disorders, this is not as important a concern as in cord-injured
clients unless head injury is suspected.
\A client arrives in the hospital emergency department with a closed head injury to
the right side of the head caused by an assault with a baseball bat. The nurse
assesses the client neurologically, looking primarily for motor response deficits that
involve which area?
1.
The left side of the body
2.
The right side of the body
3.
Both sides of the body equally
4.
Cranial nerves only, such as speech and pupillary response - ANS-1
Motor responses such as weakness and decreased movement will be seen on the
side of the body that is opposite an area of head injury. Contralateral deficits result
,from compression of the cortex of the brain or the pyramidal tracts. Depending on
the severity of the injury, the client may have a variety of neurological deficits.
\A client being mechanically ventilated after experiencing a fat embolism is visibly
anxious. What is the best nursing action?
1.
Ask a family member to stay with the client at all times.
2.
Ask the health care provider for a prescription for succinylcholine.
3.
Encourage the client to sleep until arterial blood gas results improve.
4.
Provide reassurance to the client and give small doses of morphine sulfate
intravenously as prescribed. - ANS-4
Morphine sulfate often is prescribed for pain and anxiety in the client receiving
mechanical ventilation. The nurse should speak to the client calmly and provide
reassurance to the anxious client. Family members also are stressed, not just
because of the complication but because of the original injury. It is not beneficial to
ask the family to take on the burden of remaining with the client at all times.
Succinylcholine is a neuromuscular blocker but has no antianxiety properties.
Encouraging the client to sleep until arterial blood gas results improve does nothing
to reassure or help the client.
\A client had a seizure 1 hour ago. Family members were present during the episode
and reported that the client's jaw was moving as though grinding food. In helping to
determine the origin of this seizure, what should the nurse include in the client's
assessment?
1.
Presence of diaphoresis
2.
Loss of consciousness
3.
History of prior trauma
4.
Rotating eye movements - ANS-3
,Seizures that originate with specific motor phenomena are considered focal and are
indicative of a focal structural lesion in the brain, often caused by trauma, infection,
or drug consumption. Options 1, 2, and 4 address signs, rather than an origin of the
seizure.
\A client has a chest tube attached to a water seal drainage system. As part of
routine nursing care, the nurse should ensure that which intervention is
implemented?
1.
The water seal chamber has continuous bubbling, and assessment for crepitus is
done once a shift.
2.
The amount of drainage into the chest tube is noted and recorded every 24 hours in
the client's record.
3.
The suction control chamber has sterile water added every shift, and the system is
kept below waist level.
4.
The connection between the chest tube and the drainage system is taped, and an
occlusive dressing is maintained at the insertion site. - ANS-4
The nurse ensures that all system connections are securely taped to prevent
accidental disconnection and that an occlusive dressing is maintained at the chest
tube insertion site. Continuous bubbling in the water seal chamber indicates an air
leak in the system and requires immediate investigation and correction. Drainage is
noted and recorded every hour during the first 24 hours after insertion and every 8
hours thereafter. The system is kept below the level of the waist. Assessment for
crepitus is done once every 8 hours. Sterile water is added to the suction control
chamber only as needed to replace evaporation losses.
\A client has been admitted to the hospital with a diagnosis of acute pancreatitis and
the nurse is assessing the client's pain. What type of pain is consistent with this
diagnosis?
1.
Burning and aching, located in the left lower quadrant and radiating to the hip
2.
Severe and unrelenting, located in the epigastric area and radiating to the back
3.
Burning and aching, located in the epigastric area and radiating to the umbilicus
, 4.
Severe and unrelenting, located in the left lower quadrant and radiating to the groin -
ANS-2
The pain associated with acute pancreatitis is often severe and unrelenting, is
located in the epigastric region, and radiates to the back. The other options are
incorrect.
\A client has been admitted with chest trauma after a motor vehicle crash and has
undergone subsequent intubation. The nurse checks the client when the
high-pressure alarm on the ventilator sounds, and notes that the client has absence
of breath sounds in the right upper lobe of the lung. The nurse immediately assesses
for other signs of which condition?
1.
Right pneumothorax
2.
Pulmonary embolism
3.
Displaced endotracheal tube
4.
Acute respiratory distress syndrome - ANS-1
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds
on the affected side. Pneumothorax can cause increased airway pressure because
of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that
is inserted too far can cause absent breath sounds, but the lack of breath sounds
most likely would be on the left side because of the degree of curvature of the right
and left mainstem bronchi.
\A client has clear fluid leaking from the nose following a basilar skull fracture. Which
finding would alert the nurse that cerebrospinal fluid is present?
1.
Fluid is clear and tests negative for glucose.
2.
Fluid is grossly bloody in appearance and has a pH of 6.
3.
