NCLEX practice exam 2023/ 65 questions and
answers
The nurse would need to monitor this patient for hypovolemic
shock. Symptoms of shock would include tachycardia, cool,
clammy skin and a change in level of consciousness.
Hypovolemia leads to vasoconstriction and shunting of blood to
central circulation. The patient will need to have a psychiatric
evaluation, but it is not priority.
Your patient has sustained a burn from cutaneous exposure to
lye. The patient received one hour of irrigation at the site of the
injury prior to coming to the emergency department. When you
assess the site what, finding tells you that the burn continues?
a. Eschar
b.Liquefaction necrosis
c. Cherry red, firm tissue
d. Intact blisters --correct answers-- b.Liquefaction necrosis
Liquefaction necrosis is an indication that the chemical is still
burning the patient. Exposure to acids or heat causes thick,
leathery eschars to form. Thermal injury can lead to cherry red,
firm tissue. Partial-thickness thermal injury leads to intact blisters.
Your patient in the emergency department has been sexually
assaulted. The patient is withdrawn, confused and at times
physically withdrawn. You realize that these behaviors are:
a. Sign of the patients increased risk for suicide
,b. An indication of the patient's need for admission
c. Signs of depression
d. Normal reactions to sexual assault --correct answers-- d.
Normal reactions to sexual assault
Your patient is in cardiogenic shock and has had an intraaortic
balloon pump placed through the left femoral artery. On
assessment you note that the left foot is cool and mottled and the
pedal pulse weak. What is the priority for this patient?
a. Document the data because it is expected.
b. Reevaluate in an hour.
c. Increase the rate on the nitroglycerin drip.
d. Notify the physician. --correct answers-- d. Notify the
physician.
The public should be encouraged to bring all medications and
medical records to the shelter. Space will be limited at the shelter
so they should not bring food, clothing or any type of electronics.
Animals will not be allowed at the shelter.
A nurse from the surgical care unit has been floated to your unit
for the day. Which of the following patients would you want to
assign to this nurse?
a. Exacerbation of heart failure
b. Diabetes type II, new onset
c. Emergency appendectomy
d. Thyrotoxicosis --correct answers-- c. Emergency
appendectomy
,The nurse from the surgical care unit should be comfortable
taking care of an emergency appendectomy patient. This nurse
should be most comfortable with pre- and post-operative patients;
therefore, the nurse should choose to give him or her those
patients if available.
A patient inquires about the therapeutic uses of marijuana. You
know that marijuana is used for what therapeutic use?
a. Stimulating appetite
b. Stimulating energy
c. Reducing stress
d. Antibacterial agent --correct answers-- a. Stimulating
appetite
A patient who has been assaulted is exhibiting signs of
hyperventilation, pacing, rapid speech and headache. What level
of anxiety is this patient in?
a. Panic
b. Severe
c. Moderate
d. Psychotic --correct answers-- b. severe
This patient is displaying the signs of severe anxiety. This patient
would display signs of hyperventilation, purposeless activity, loud,
rapid speech and headache. The other three options are
incorrect.
An elderly patient comes into the emergency department to rule
out stroke. On admission, vital signs are pulse 90, blood pressure
150/100, and respirations 20. An IV is run for the patient. Upon
reassessment 30 minutes later, vital signs are pulse 78, blood
, pressure 170/90, and respirations 24 and irregular. What action
should the nurse consider taking?
a. Have the patient describe how they are feeling
b. Check the patient's Dilantin level
c. Decrease fluids
d. Encourage the patient to drink --correct answers-- c.
Decrease fluids
a. Cyanosis
b. Hypotension
c. Dyspnea, especially on exhalation
d. Paradoxical chest movement --correct answers-- d.
Paradoxical chest movement
A patient with flail chest would have paradoxical chest movement.
The flail chest comes from several sections of rib being broken,
resulting in a floating section of ribs. This small section moves the
opposite direction of the rest of the chest during inspiration and
expiration.
What is the anticipated therapeutic effect of an escharotomy?
a. Bleeding from the site
b. Formation of granulation tissue
c, Decreasing edema formation
d. Return of distal pulses --correct answers-- d. Return of
distal pulses
The purpose of escharotomy is to relieve compartment syndrome
and facilitate the return of distal pulses. Bleeding is considered to
answers
The nurse would need to monitor this patient for hypovolemic
shock. Symptoms of shock would include tachycardia, cool,
clammy skin and a change in level of consciousness.
Hypovolemia leads to vasoconstriction and shunting of blood to
central circulation. The patient will need to have a psychiatric
evaluation, but it is not priority.
Your patient has sustained a burn from cutaneous exposure to
lye. The patient received one hour of irrigation at the site of the
injury prior to coming to the emergency department. When you
assess the site what, finding tells you that the burn continues?
a. Eschar
b.Liquefaction necrosis
c. Cherry red, firm tissue
d. Intact blisters --correct answers-- b.Liquefaction necrosis
Liquefaction necrosis is an indication that the chemical is still
burning the patient. Exposure to acids or heat causes thick,
leathery eschars to form. Thermal injury can lead to cherry red,
firm tissue. Partial-thickness thermal injury leads to intact blisters.
Your patient in the emergency department has been sexually
assaulted. The patient is withdrawn, confused and at times
physically withdrawn. You realize that these behaviors are:
a. Sign of the patients increased risk for suicide
,b. An indication of the patient's need for admission
c. Signs of depression
d. Normal reactions to sexual assault --correct answers-- d.
Normal reactions to sexual assault
Your patient is in cardiogenic shock and has had an intraaortic
balloon pump placed through the left femoral artery. On
assessment you note that the left foot is cool and mottled and the
pedal pulse weak. What is the priority for this patient?
a. Document the data because it is expected.
b. Reevaluate in an hour.
c. Increase the rate on the nitroglycerin drip.
d. Notify the physician. --correct answers-- d. Notify the
physician.
The public should be encouraged to bring all medications and
medical records to the shelter. Space will be limited at the shelter
so they should not bring food, clothing or any type of electronics.
Animals will not be allowed at the shelter.
A nurse from the surgical care unit has been floated to your unit
for the day. Which of the following patients would you want to
assign to this nurse?
a. Exacerbation of heart failure
b. Diabetes type II, new onset
c. Emergency appendectomy
d. Thyrotoxicosis --correct answers-- c. Emergency
appendectomy
,The nurse from the surgical care unit should be comfortable
taking care of an emergency appendectomy patient. This nurse
should be most comfortable with pre- and post-operative patients;
therefore, the nurse should choose to give him or her those
patients if available.
A patient inquires about the therapeutic uses of marijuana. You
know that marijuana is used for what therapeutic use?
a. Stimulating appetite
b. Stimulating energy
c. Reducing stress
d. Antibacterial agent --correct answers-- a. Stimulating
appetite
A patient who has been assaulted is exhibiting signs of
hyperventilation, pacing, rapid speech and headache. What level
of anxiety is this patient in?
a. Panic
b. Severe
c. Moderate
d. Psychotic --correct answers-- b. severe
This patient is displaying the signs of severe anxiety. This patient
would display signs of hyperventilation, purposeless activity, loud,
rapid speech and headache. The other three options are
incorrect.
An elderly patient comes into the emergency department to rule
out stroke. On admission, vital signs are pulse 90, blood pressure
150/100, and respirations 20. An IV is run for the patient. Upon
reassessment 30 minutes later, vital signs are pulse 78, blood
, pressure 170/90, and respirations 24 and irregular. What action
should the nurse consider taking?
a. Have the patient describe how they are feeling
b. Check the patient's Dilantin level
c. Decrease fluids
d. Encourage the patient to drink --correct answers-- c.
Decrease fluids
a. Cyanosis
b. Hypotension
c. Dyspnea, especially on exhalation
d. Paradoxical chest movement --correct answers-- d.
Paradoxical chest movement
A patient with flail chest would have paradoxical chest movement.
The flail chest comes from several sections of rib being broken,
resulting in a floating section of ribs. This small section moves the
opposite direction of the rest of the chest during inspiration and
expiration.
What is the anticipated therapeutic effect of an escharotomy?
a. Bleeding from the site
b. Formation of granulation tissue
c, Decreasing edema formation
d. Return of distal pulses --correct answers-- d. Return of
distal pulses
The purpose of escharotomy is to relieve compartment syndrome
and facilitate the return of distal pulses. Bleeding is considered to
