Nclex - failed questions review

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. A. Fever B. Night sweats C. Osler nodes D. Cardiac murmur E. Syncope F. Weight loss - AChoices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet). The nurse has provided education to a client diagnosed with obstructive sleep apnea (OSA). Which client statement would indicate a correct understanding of the teaching? A. "I should use an antiseptic mouthwash immediately before going to bed." B. "I will plan on exercising at least 150 minutes a week." C. "I have been reading about the potential for me needing supplemental oxygen overnight." D. "I will sleep flat on my bed without any pillows." - Acorrect answer is B A crucial part of mitigating the symptoms of obstructive sleep apnea is for a client to lose weight. Weight reduction is a pivotal part of the treatment plan for an individual with OSA, as being overweight or obese causes fat deposits in the upper airways. Reducing these fat deposits improves muscle activity and allows for better ventilation. The client stated that they plan on exercising 150 minutes a week is a favorable response because that is the national recommendation incorrect C: The primary issue with OSA is not low oxygen; the tongue, soft palate, and other neck muscles relax, causing displacement and obstruction. This impediment causes the client to retain carbon dioxide, which explains why they have a headache in the morning and do not feel rested. Low oxygen is also found, but supplemental oxygen is not the remedy, as continuous positive airway pressure (CPAP) is the gold standard because of its positive pressure. The positive pressure keeps the upper airways open, allowing gas exchange. The client requires positive pressure, not oxygen. When caring for a client with total parenteral nutrition (TPN), what is the most important action by the nurse? A. Record the number of stools per day B. Maintain strict intake and output records C. Sterile technique for dressing change at IV site D. Monitor for cardiac arrhythmias - AChoice C is correct. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site. Choices A, B, and D are incorrect. Although these are appropriate nursing interventions, they are not the essential action of the nurse in this example. The nurse is caring for a client with a chest tube drainage system. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that: A. There may be fibrin clots in the tubing B. The lung is collapsing C. There has been an increase in intrapleural pressure D. The tubing may have become dislodged from the chest - AChoice A is correct. Fluctuation in the water seal column of a chest tube drainage system typically indicates proper functioning of the system. Cessation of fluctuation may occur due to various reasons, but one common cause is the presence of fibrin clots in the tubing. Fibrin clots can obstruct the flow of air and fluid within the tubing, leading to the absence of fluctuation. This situation should be promptly assessed and addressed to ensure proper drainage and prevent complications. This may also occur when the lung becomes fully expanded. Choice B is incorrect. Fluctuation in the water seal column of a chest tube drainage system is a sign that the lung is re-expanding and that the drainage system is working correctly. Choice C is incorrect. Fluctuation in the water seal column occurs as a result of changes in intrapleural pressure during the respiratory cycle. When intrapleural pressure increases during inhalation, the fluid in the water seal chamber is pulled upward, creating a positive pressure. During exhalation, the fluid in the chamber is pushed back down as intrapleural pressure decreases. Choice D is incorrect. f the tubing of the chest tube drainage system becomes dislodged or disconnected from the chest, it can lead to a loss of suction and fluctuation. While this is a potential concern, the presence of fibrin clots in the tubing (Option A) is a more common and direct explanation for fluctuation cessation. Which of the following conditions would be a possible cause of hyperactive bowel sounds? Incorrect A. Paralytic ileus B. Gastroenteritis C. Late bowel obstruction D. Peritonitis - AChoice B is correct. Of the options listed, gastroenteritis would be the only possible cause of hyperactive bowel sounds. Choice A is incorrect. Paralytic ileus would result in hypoactive (diminished) bowel sounds, not hyperactive. Choice C is incorrect. Late bowel obstruction would be associated with hypoactive or absent bowel sounds. Choice D is incorrect. Peritonitis would result in diminished bowel sounds due to inflammation. The nurse is reviewing an EKG strip for a client. Which of the following rhythm changes could impact the patient's cardiac output? Supraventricular tachycardia Sinus bradycardia Ventricular tachycardia Mobitz type II heart block Isolated premature atrial contraction (PAC) - AAll rhythm changes will affect cardiac output. This is especially important to remember when administering antiarrhythmics to your client, as these medications and their effect will also change the cardiac output. There are two reasons that rhythm changes affect cardiac output. 1 - they break your heart rate. 2 - they change your stroke volume. Remember, CO = HR x SV, so any change to either heart rate or stroke volume subsequently affects your cardiac output. A - Supraventricular tachycardia (SVT) - There is an increase in heart rate but a decrease in stroke volume. This is because the heart is beating so fast that there is not enough time for diastole and, therefore, not enough time for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Clients with SVT have decreased cardiac output. B - Sinus bradycardia - The heart rate is lower due to bradycardia, so the cardiac output is lowered. Remember, CO = HR x SV. Decreased HR = decreased CO. C - Ventricular tachycardia - There is an increase in heart rate and a decrease in stroke volume. This is because the heart is beating fast and irregularly. There is not enough time for diastole and, therefore, for the atriums to fill with blood. This decreases preload, which decreases contractility due to Starling's law, which reduces stroke volume. Clients in VT have decreased cardiac output. This is a lethal rhythm. D - Mobitz type II heart block - This type of heart block causes a decreased heart rate, which once again reduces cardiac output. CO = HR x SV. Decreased HR = decreased CO. Clients in Mobitz type II heart block have decreased cardiac output. The nurse is assessing a client with peripheral arterial disease (PAD). Which of the following findings would the nurse expect to observe? Select all that apply. Decreased peripheral pulses Pain with ambulation Reddish-brown ankle discoloration Bilateral dependent edema Protruding veins in the leg - AChoices A and B are correct. Peripheral arterial disease (PAD) is characterized by atherosclerosis in the lumen of the peripheral arteries. PAD symptoms include pain in the extremities that may be exacerbated by walking and are relieved by rest (claudication). Decreased peripheral pulses are a consistent manifestation of PAD. Choices C, D, and E are incorrect. Hyperpigmentation of the ankles with edema is a finding consistent with venous insufficiency(peripheral venous disease, PVD) (choice C). Other features of venous insufficiency include protruding veins in the leg and telangiectasia (choice E). Peripheral pulses are typically normal in venous insufficiency. Edema is seen with PVD, not PAD. Edema is not associated with PAD because the issue is with an impediment in distal blood flow. When blood flow cannot return because of venous insufficiency, this causes the client to develop pedal edema (choice D). When caring for a client with total parenteral nutrition (TPN), what is the most important action by the nurse? A. Record the number of stools per day [1%] B. Maintain strict intake and output records [32%] C. Sterile technique for dressing change at IV site [44%] D. Monitor for cardiac arrhythmias - AChoice C is correct. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site. Choices A, B, and D are incorrect. Although these are appropriate nursing interventions, they are not the essential action of the nurse in this example.