Nclex- Cris-test I UPDATED ACTUAL
Questions and CORRECT Answers
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the
nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST
appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT
ANSWER - 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the
risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and
breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain
into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
A young adult brings a friend to the emergency department and states that the friend has been
using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. - CORRECT ANSWER - 1) Assessment:
outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
,2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be
seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?" - CORRECT ANSWER - 1) Assessment:
outcome not priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed for further
teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases
heart rate and myocardial oxygen consumption; increased risk of angina and myocardial
infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and
gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of morphine
during the last hour. Which is the MOST appropriate action for the nurse to take?
,1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - CORRECT ANSWER - 1) Assessment: outcome
not priority but may be appropriate; if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain
level, description of the pain, region and radiation of the pain, and relieving factors
3) Implementation: outcome not desired; more important to assess severity of pain and pain relief
first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse
is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - CORRECT ANSWER - 1)
Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
output; fetal pressure on inferior vena cava reduced
, 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal
pressure on vena cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which
finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. - CORRECT ANSWER - 1) CORRECT - Assessment:
outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased
and concentrated
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime. - CORRECT ANSWER - 1) Implementation:
outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant
2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis;
first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation;
combination of vasodilation and diuresis increases risk of orthostatic hypotension
Questions and CORRECT Answers
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the
nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST
appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT
ANSWER - 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the
risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and
breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain
into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
A young adult brings a friend to the emergency department and states that the friend has been
using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. - CORRECT ANSWER - 1) Assessment:
outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
,2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be
seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?" - CORRECT ANSWER - 1) Assessment:
outcome not priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed for further
teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases
heart rate and myocardial oxygen consumption; increased risk of angina and myocardial
infarction
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and
gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of morphine
during the last hour. Which is the MOST appropriate action for the nurse to take?
,1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - CORRECT ANSWER - 1) Assessment: outcome
not priority but may be appropriate; if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain
level, description of the pain, region and radiation of the pain, and relieving factors
3) Implementation: outcome not desired; more important to assess severity of pain and pain relief
first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse
is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - CORRECT ANSWER - 1)
Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
output; fetal pressure on inferior vena cava reduced
, 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal
pressure on vena cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which
finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. - CORRECT ANSWER - 1) CORRECT - Assessment:
outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased
and concentrated
2) Assessment: outcome not priority; indicates that blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is 120/80
The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime. - CORRECT ANSWER - 1) Implementation:
outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant
2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis;
first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation;
combination of vasodilation and diuresis increases risk of orthostatic hypotension
