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NUR 101 NCLEX TEST TAKING STRATEGY EXAM ||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|| SURE PASS!!
• . The daytime charge nurse identifies that a client was treated for what
condition during the night after reading the following chart entries?
o 1. Respiratory Alkalosis
o 2. Respiratory Acidosis
o 3. Metabolic Alkalosis
o 4. Metabolic Acidosis
Rationale:
2. Correct: Look at pH? Acid and which other lab says acid….CO2. Is CO2 a
respiratory or metabolic chemical? Respiratory. So the condition is Respiratory
Acidosis.
1. Incorrect: Not alkalotic condition, the pH is acid.
3. Incorrect: Not metabolic condition, because HCO3 is normal.
4. Incorrect: Not metabolic condition, because HCO3 is normal.
• The nurse is caring for a client, who is 8 hours post- op receiving 40%
humidified oxygen. ABG results are: pO2= 91, pCO2= 50, pH= 7.30, HCO3= 24.
Based on this information, which nursing action would be best?
o 1. Turn client and encourage coughing and deep breathing.
o 2. Request respiratory therapy to perform postural drainage and percussion.
o 3. Report ABGs to physician and increase oxygen percentage.
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o 4. Administer anti-anxiety agent.
Rationale:
1.Correct: If you are 8 hours post-op would you be taking nice deep breaths? No.
So what would you be retaining? CO2 which makes your pCO2 go up, which
makes your pH go down. I’m acidotic aren’t I?
2. Incorrect: Requesting postural drainage and percussion form respiratory
therapy would not be the best nursing action to address the problem of retaining
CO2.
3. Incorrect: There’s nothing wrong with calling the physician and letting him
know about the ABGs but the last part is just wrong. How is oxygen going to help
this client? It’s not until they get rid of the what? CO2. And the only way to rid of
the CO2 is coughing and deep breathing.
4. Incorrect: What are they going to say about you if you select #4? You’re a
killer. Don’t give her a license, because if you give them an anti-anxiety agent
what’s going to happen to the respiratory rate, decrease, and they are going to
retain even more CO2 and you’ve just made it worse.
• . After completing a round of chemotherapy, the client’s lab results revealed.
Based on this data, what problem should the nurse anticipate? Select all that apply.
1. Anemia
2. Leukopenia
3. Thrombocytopenia
4. Hypernatremia
5. Hypokalemia
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Rationale:
1., 2. & 3. Correct: Chemotherapy decreases bone marrow production, resulting in
reduced red blood cell counts (anemia), reduced white blood cell counts
(leukopenia), and reduced platelet counts (thrombocytopenia).
4. Incorrect: The sodium level is normal.
5. Incorrect: The potassium level is also normal.
12. A client weighing 154 pounds is admitted to the burn unit with second and
third degree burns covering 40% total body surface area. Normal Saline IV fluid
resuscitation is ordered at 4 ml/kg per percentage of total body surface area burned
over the first 24 hours. How much fluid does the nurse calculate the client will
receive in 24 hours?
Provide your answer in whole numbers
ml
Rationale:
Correct: 11,200 ml in the first 24 hours
154 pounds/ 2.2 kg= 70 kg
4 ml x 70 kg= 280
280 ml x 40 tbsa= 11,200 ml in the first 24 hours
13. A client five days post electrical burn states, “I am feeling fine and would
like to go home.” What is the rationale for this length of stay?
o 1. Bone damage always occurs resulting in pathologic fractures.
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o 2. Vascular and nerve damage may cause organ failure.
o 3. Continuous EKG monitoring is always required.
o 4. Infection is sometimes a delayed response.
Rationale:
2. Correct: The current of electrical burns damages the vascular system and the
nerves nearby. This alteration in the vascular system can damage vital organs, and
we worry about organ failure.
1. Incorrect: Bones are dense and not really affected by electrical current.
3. Incorrect: Cardiac monitoring is for the first 48 hours, not the reason for a
prolonged stay.
4. Incorrect: Infection is not a priority in an electrical burn.
• A client is hospitalized hundreds of miles from home for a bone marrow
transplant. The client is in reverse isolation while undergoing total body irradiation
and intense chemotherapy. The client’s sibling, who has driven a great distance,
comes to visit and has obvious manifestations of an upper respiratory infection.
Which nursing action would be most appropriate at this time?
o 1. Do not allow the sibling to visit, and do not upset the client by mentioning
the sibling’s visit.
o 2. Allow the sibling to wave at the client through the window or door, then
offer the use of the unit phone so they can talk.
o 3. Allow the sibling to visit donning a sterile gown, mask, and gloves, but
prohibit physical contact.
o 4. Allow the sibling to visit after donning a sterile gown, mask, and gloves
and have the client wear a mask.
Rationale:
NUR 101 NCLEX TEST TAKING STRATEGY EXAM ||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|| SURE PASS!!
• . The daytime charge nurse identifies that a client was treated for what
condition during the night after reading the following chart entries?
o 1. Respiratory Alkalosis
o 2. Respiratory Acidosis
o 3. Metabolic Alkalosis
o 4. Metabolic Acidosis
Rationale:
2. Correct: Look at pH? Acid and which other lab says acid….CO2. Is CO2 a
respiratory or metabolic chemical? Respiratory. So the condition is Respiratory
Acidosis.
1. Incorrect: Not alkalotic condition, the pH is acid.
3. Incorrect: Not metabolic condition, because HCO3 is normal.
4. Incorrect: Not metabolic condition, because HCO3 is normal.
• The nurse is caring for a client, who is 8 hours post- op receiving 40%
humidified oxygen. ABG results are: pO2= 91, pCO2= 50, pH= 7.30, HCO3= 24.
Based on this information, which nursing action would be best?
o 1. Turn client and encourage coughing and deep breathing.
o 2. Request respiratory therapy to perform postural drainage and percussion.
o 3. Report ABGs to physician and increase oxygen percentage.
,2|Page
o 4. Administer anti-anxiety agent.
Rationale:
1.Correct: If you are 8 hours post-op would you be taking nice deep breaths? No.
So what would you be retaining? CO2 which makes your pCO2 go up, which
makes your pH go down. I’m acidotic aren’t I?
2. Incorrect: Requesting postural drainage and percussion form respiratory
therapy would not be the best nursing action to address the problem of retaining
CO2.
3. Incorrect: There’s nothing wrong with calling the physician and letting him
know about the ABGs but the last part is just wrong. How is oxygen going to help
this client? It’s not until they get rid of the what? CO2. And the only way to rid of
the CO2 is coughing and deep breathing.
4. Incorrect: What are they going to say about you if you select #4? You’re a
killer. Don’t give her a license, because if you give them an anti-anxiety agent
what’s going to happen to the respiratory rate, decrease, and they are going to
retain even more CO2 and you’ve just made it worse.
• . After completing a round of chemotherapy, the client’s lab results revealed.
Based on this data, what problem should the nurse anticipate? Select all that apply.
1. Anemia
2. Leukopenia
3. Thrombocytopenia
4. Hypernatremia
5. Hypokalemia
,3|Page
Rationale:
1., 2. & 3. Correct: Chemotherapy decreases bone marrow production, resulting in
reduced red blood cell counts (anemia), reduced white blood cell counts
(leukopenia), and reduced platelet counts (thrombocytopenia).
4. Incorrect: The sodium level is normal.
5. Incorrect: The potassium level is also normal.
12. A client weighing 154 pounds is admitted to the burn unit with second and
third degree burns covering 40% total body surface area. Normal Saline IV fluid
resuscitation is ordered at 4 ml/kg per percentage of total body surface area burned
over the first 24 hours. How much fluid does the nurse calculate the client will
receive in 24 hours?
Provide your answer in whole numbers
ml
Rationale:
Correct: 11,200 ml in the first 24 hours
154 pounds/ 2.2 kg= 70 kg
4 ml x 70 kg= 280
280 ml x 40 tbsa= 11,200 ml in the first 24 hours
13. A client five days post electrical burn states, “I am feeling fine and would
like to go home.” What is the rationale for this length of stay?
o 1. Bone damage always occurs resulting in pathologic fractures.
, 4|Page
o 2. Vascular and nerve damage may cause organ failure.
o 3. Continuous EKG monitoring is always required.
o 4. Infection is sometimes a delayed response.
Rationale:
2. Correct: The current of electrical burns damages the vascular system and the
nerves nearby. This alteration in the vascular system can damage vital organs, and
we worry about organ failure.
1. Incorrect: Bones are dense and not really affected by electrical current.
3. Incorrect: Cardiac monitoring is for the first 48 hours, not the reason for a
prolonged stay.
4. Incorrect: Infection is not a priority in an electrical burn.
• A client is hospitalized hundreds of miles from home for a bone marrow
transplant. The client is in reverse isolation while undergoing total body irradiation
and intense chemotherapy. The client’s sibling, who has driven a great distance,
comes to visit and has obvious manifestations of an upper respiratory infection.
Which nursing action would be most appropriate at this time?
o 1. Do not allow the sibling to visit, and do not upset the client by mentioning
the sibling’s visit.
o 2. Allow the sibling to wave at the client through the window or door, then
offer the use of the unit phone so they can talk.
o 3. Allow the sibling to visit donning a sterile gown, mask, and gloves, but
prohibit physical contact.
o 4. Allow the sibling to visit after donning a sterile gown, mask, and gloves
and have the client wear a mask.
Rationale:
