NCLEX CRIS Test I – Questions With Accurate
Solutions
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
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 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
Solutions
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
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 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
