The nurse is taking the health history of a patient blood in the stool which presents as black, tarry
being treated for Emphysema and Chronic feces. This is a common manifestation of
Bronchitis. After being told the patient has been Duodenal Ulcers, since the Duodenum is further
smoking cigarettes for 30 years, the nurse down the gastric anatomy.
expects to note which assessment finding?
2. Nausea
1. Increase in Forced Vital Capacity (FVC) Nausea may be present, but is a generalized
2. A narrowed chest cavity symptom and by itself doesn't indicate a
3. Clubbed fingers Duodenal Ulcer. Incorrect.
4. An increased risk of cardiac failure -
ANSWER -1. Increase in Forced Vital 3. Hernia
Capacity (FVC) A Hernia is a protrusion of a segment of the
Forced Vital Capacity is the volume of air abdomen through another abdominal structure. It
exhaled from full inhalation to full exhalation. A is not associated with an Ulcer and is a condition,
patient with COPD would have a decrease in not an assessment finding. Incorrect.
FVC. Incorrect.
4. Hyperthermia
2. A narrowed chest cavity Hyperthermia, a high temperature, is not an
A patient with COPD often presents with a 'barrel assessment finding of a Duodenal Ulcer.
chest,' which is seen as a widened chest cavity. Incorrect
Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or A nurse is providing discharge teaching for a
chronic, decrease in oxygen levels. patient with severe Gastroesophogeal Reflux
Disease. Which of these statements by the
4. An increased risk of cardiac failure patient indicates a need for more teaching?
Although a patient with these conditions would
indeed be at an increased risk for cardiac failure, 1. "I'm going to limit my meals to 2-3 per day to
this is a potential complication and not an reduce acid secretion."
assessment finding. Incorrect.
2. "I'm going to make sure to remain upright after
meals and elevate my head when I sleep"
The nurse is taking the health history of a 70- 3. "I won't be drinking tea or coffee or eating
year-old patient being treated for a Duodenal chocolate any more."
Ulcer. After being told the patient is complaining
of epigastric pain, the nurse expects to note 4. "I'm going to start trying to lose some weight." -
which assessment finding? ANSWER -1. "I'm going to limit my meals to
2-3 per day to reduce acid secretion."
1. Melena CORRECT - Large meals increase the volume
2. Nausea and pressure in the stomach and delay gastric
3. Hernia emptying. It's recommended instead to eat 4-6
4. Hyperthermia - ANSWER -1. Melena - small meals a day.
CORRECT
Melena is the finding that there are traces of 2. "I'm going to make sure to remain upright after
,75 Free NCLEX Questions and Answers Rated A
meals and elevate my head when I sleep" Incorrect - While this is an important intervention
Incorrect - This is a correct verbalization of health to manage pain, it is not the priority intervention.
promotion for GERD.
3. "I won't be drinking tea or coffee or eating
chocolate any more." A female patient with atrial fibrillation has the
Incorrect - This is a correct verbalization of health following lab results: Hemoglobin of 11 g/dl, a
promotion for GERD. platelet count of 150,000, an INR of 2.5, and
potassium of 2.7 mEq/L. Which result is critical
4. "I'm going to start trying to lose some weight." and should be reported to the physician
Incorrect - This is a correct verbalization of health immediately?
promotion for GERD.
1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
The nurse in the Emergency Room is treating a 4. Potassium of 2.7 mEq/L - ANSWER -1.
patient suspected to have a Peptic Ulcer. On Hemoglobin 11 g/dl
assessing lab results, the nurse finds that the This is below normal, but a normal female
patient's blood pressure is 95/60, pulse is 110 hemoglobin is 12-14. There is a more critical lab
beats per minute, and the patient reports result.
epigastric pain. What is the PRIORITY
intervention? 2. Platelet of 150,000
This is also below the normal values, but is not
1. Start a large-bore IV in the patient's arm the most critical lab result.
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube 3. INR of 2.5
4. Administer intramuscular morphine sulphate This is a therapeutic range for a patient who is
as ordered - ANSWER -1. Start a large- taking an anticoagulant for atrial fibrillation
bore IV in the patient's arm
CORRECT - The nurse should suspect that the 4. Potassium of 2.7 mEq/L
patient is haemorrhaging and will need need a CORRECT - A potassium imbalance for a patient
fluid replacement therapy, which requires a large with a history of dysrhythmia can be life-
bore IV. threatening and can lead to cardiac distress.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis
and assessment of Peptic Ulcer Disease, it is not While receiving normal saline infusions to treat a
the priority intervention. GI bleed, the nurse notes that the patient's lower
legs have become edematous and auscultates
3. Prepare to insert an NG Tube crackles in the lungs. What should the nurse do
Incorrect - While this intervention may be used in first?
the later stages of Peptic Ulcer Disease, it is not
the first and priority intervention. 1. Stop the saline infusion immediately
2. Notify Physician
4. Administer intramuscular morphine sulphate 3. Elevate the patient's legs
as ordered 4. Continue the infusion, since these are normal
, 75 Free NCLEX Questions and Answers Rated A
findings - ANSWER -1. Stop the saline can prevent transmission of HIV.
infusion immediately
CORRECT - the patient has a fluid volume 4. They must avoid large crowds
overload as a result of overly rapid fluid Incorrect - Avoiding large crowds to prevent
replacement. The nurse should stop the infusion infection is a priority in the later stages of HIV,
and notify the physician. when the patient has AIDS.
2. Notify Physician
This is not the first action the nurse should take.
A nurse finds a 30-year-old woman experiencing
3. Elevate the patient's legs anaphylaxis from a bee sting. Emergency
This would help with the edema, but is not a personnel have been called. The nurse notes the
priority woman is breathing but short of breath. Which of
the following interventions should the nurse do
4. Continue the infusion, since these are normal first?
findings
This is not a normal finding 1. Initiate cardiopulmonary resuscitation
2. Check for a pulse
3. Ask the woman if she carries an emergency
medical kit
The nurse is working in a support group for 4. Stay with the woman until help comes -
clients with HIV. Which point is most important ANSWER -1. Initiate cardiopulmonary
for the nurse to stress? resuscitation
Incorrect - CPR is premature at this point, and
1. They must inform household members of their there is another action that can be taken first.
condition
2. They must take their medications exactly as 2. Check for a pulse
prescribed This is the first step when assessing for initiation
3. They must abstain from substance use of CPR, but CPR is not the best and first course
4. They must avoid large crowds - of action for this situation. The woman is still
ANSWER -1. They must inform household breathing, which means CPR is not necessary at
members of their condition this time.
Incorrect - Each patient has a right to privacy of
their medical condition. It is their choice whether 3. Ask the woman if she carries an emergency
they inform household members. medical kit
CORRECT - Many patients who have a known
2. They must take their medications exactly as history of anaphylaxis carry epi-pens in their
prescribed pockets or belongings. This is the best way to
CORRECT - Antiretrovirals must be taken stop a hypersensitivity reaction before it becomes
exactly as prescribed to prevent drug-resistant life-threatening.
strains. Even missed doses can reduce the
effectiveness of future treatment. 3. Stay with the woman until help comes
Incorrect - While this should be done, it's not the
3. They must abstain from substance use best and first course of action.
Incorrect - While substance use should be
discouraged, using safe practices with needles