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NCLEX Exam Final || Most Recent Exam Actual
Complete Real Verified Exam Questions And Correct
Answers (Verified Answers) Already Graded A+ |
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Emergency department triage is an important nursing
function. A nurse working the evening shift is presented
with four patients at the same time. Which of the following
patients should be assigned the highest priority?
A. A patient with low-grade fever, headache, and myalgias
for the past 72 hours.
B. A patient who is unable to bear weight on the left foot,
with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a
large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin
but otherwise well after falling while jumping on his bed. -
Answer-Answer: C
Emergency triage involves quick patient assessment to
prioritize the need for further evaluation and care. Patients
with trauma, chest pain, respiratory distress, or acute
neurological changes are always classified number one
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priority. Though the patient with chest pain presented in
the question recently ate a spicy meal and may be
suffering from heartburn, he also may be having an acute
myocardial infarction and require urgent attention. The
patient with fever, headache and muscle aches (classic flu
symptoms) should be classified as non-urgent. The patient
with the foot injury may have sustained a sprain or
fracture, and the limb should be x-rayed as soon as is
practical, but the damage is unlikely to worsen if there is a
delay. The child's chin laceration may need to be sutured
but is also non-urgent.
A nurse cares for a patient who has a nasogastric tube
attached to low suction because of a suspected bowel
obstruction. Which of the following arterial blood gas
results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg. - Answer-Answer: A
A patient on nasogastric suction is at risk of metabolic
alkalosis as a result of loss of hydrochloric acid in gastric
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fluid. Of the answers given, only answer A (pH 7.52, PCO2
54 mm Hg) represents alkalosis. Answer B is a normal
blood gas. Answer C represents respiratory acidosis.
Answer D is borderline normal with slightly low PCO2.
A patient is admitted to the emergency department after
sustaining abdominal injuries and a broken femur from a
motor vehicle accident. The patient is pale, diaphoretic,
and is not talking coherently. Vital signs upon admission
are temperature 98 F (36 C), heart rate 130 beats/minute,
respiratory rate 34 breaths/minute, blood pressure 50/40
mmHg. The healthcare provider suspects which type of
shock?
a.) Hypovolemic
b.) Cardiogenic
c.) Neurogenic
d.) Septic - Answer-a.) Hypovolemic
The healthcare provider is caring for a patient who has
septic shock. Which of these should the healthcare
provider administer to the patient first?
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a.) Antibiotics to treat the underlying infection.
b.) Corticosteroids to reduce inflammation.
c.) IV fluids to increase intravascular volume.
d.) Vasopressors to increase blood pressure. - Answer-c.)
IV fluids to increase intravascular volume.
Rationale:
Circulation and perfusion are addressed first so IV fluids
will be started immediately. After blood cultures are
obtained, broad-spectrum antibiotics should be
administered without delay. Vasopressors are
administered if the patient is not responding to the fluid
challenge. Corticosteroids may be considered to address
the inflammatory-induced vasodilation and capillary
leakage
Which of the following assessment findings is an early
indication of hypovolemic shock?
a.) Diminished bowel sounds
b.) Increased urinary output
c.) Tachycardia
NCLEX Exam Final || Most Recent Exam Actual
Complete Real Verified Exam Questions And Correct
Answers (Verified Answers) Already Graded A+ |
Guaranteed Success!! Newest Exam!!!
Emergency department triage is an important nursing
function. A nurse working the evening shift is presented
with four patients at the same time. Which of the following
patients should be assigned the highest priority?
A. A patient with low-grade fever, headache, and myalgias
for the past 72 hours.
B. A patient who is unable to bear weight on the left foot,
with swelling and bruising following a running accident.
C. A patient with abdominal and chest pain following a
large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin
but otherwise well after falling while jumping on his bed. -
Answer-Answer: C
Emergency triage involves quick patient assessment to
prioritize the need for further evaluation and care. Patients
with trauma, chest pain, respiratory distress, or acute
neurological changes are always classified number one
,2|Page
priority. Though the patient with chest pain presented in
the question recently ate a spicy meal and may be
suffering from heartburn, he also may be having an acute
myocardial infarction and require urgent attention. The
patient with fever, headache and muscle aches (classic flu
symptoms) should be classified as non-urgent. The patient
with the foot injury may have sustained a sprain or
fracture, and the limb should be x-rayed as soon as is
practical, but the damage is unlikely to worsen if there is a
delay. The child's chin laceration may need to be sutured
but is also non-urgent.
A nurse cares for a patient who has a nasogastric tube
attached to low suction because of a suspected bowel
obstruction. Which of the following arterial blood gas
results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg. - Answer-Answer: A
A patient on nasogastric suction is at risk of metabolic
alkalosis as a result of loss of hydrochloric acid in gastric
,3|Page
fluid. Of the answers given, only answer A (pH 7.52, PCO2
54 mm Hg) represents alkalosis. Answer B is a normal
blood gas. Answer C represents respiratory acidosis.
Answer D is borderline normal with slightly low PCO2.
A patient is admitted to the emergency department after
sustaining abdominal injuries and a broken femur from a
motor vehicle accident. The patient is pale, diaphoretic,
and is not talking coherently. Vital signs upon admission
are temperature 98 F (36 C), heart rate 130 beats/minute,
respiratory rate 34 breaths/minute, blood pressure 50/40
mmHg. The healthcare provider suspects which type of
shock?
a.) Hypovolemic
b.) Cardiogenic
c.) Neurogenic
d.) Septic - Answer-a.) Hypovolemic
The healthcare provider is caring for a patient who has
septic shock. Which of these should the healthcare
provider administer to the patient first?
, 4|Page
a.) Antibiotics to treat the underlying infection.
b.) Corticosteroids to reduce inflammation.
c.) IV fluids to increase intravascular volume.
d.) Vasopressors to increase blood pressure. - Answer-c.)
IV fluids to increase intravascular volume.
Rationale:
Circulation and perfusion are addressed first so IV fluids
will be started immediately. After blood cultures are
obtained, broad-spectrum antibiotics should be
administered without delay. Vasopressors are
administered if the patient is not responding to the fluid
challenge. Corticosteroids may be considered to address
the inflammatory-induced vasodilation and capillary
leakage
Which of the following assessment findings is an early
indication of hypovolemic shock?
a.) Diminished bowel sounds
b.) Increased urinary output
c.) Tachycardia
