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NCLEX-RN Exam Questions - Part 99
1. A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the clients nursing assessment demand immediate nursing action?
A) Associated symptoms of indigestion and nausea
B) Restlessness and apprehensiveness
C) Inability to tolerate assessment session with the admitting nurse
D) History of hypertension treated with pharmacological therapy
2. A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
A) Serum osmolality is elevated indicating hemoconcentration.The nurse should increase IV fluid rate.
B) Serum sodium is low. The nurse should change IV fluids to normal saline.
C) Blood urea nitrogen is subnormal. The nurse should increase the protein in the client - s diet as soon as possible.
D) Serum potassium is low. The nurse should administer KCl as ordered.
3. A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can - t you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse - s greatest concern is that:
A) The client may contract an infection as a result of being exposed to large crowds at spring break
B) The client does not grasp the full impact of her illness
C) The client may require transfusion before leaving for spring break
D) The causative agent be identified and treatment begun
4. A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?
A) Hematocrit levels usually remain slightly below normalin clients with renal failure.
B) Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.
C) Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.
D) The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.
5. A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made.During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A) 'I have not been drinking six to eight glasses of water each day as the nurse had instructed.'
B) 'I - m afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I - ve been married.'
C) 'I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time.'
D) 'I recently had the flu, which could be settling in my kidneys now.'
A) Associated symptoms of indigestion and nausea
B) Restlessness and apprehensiveness
C) Inability to tolerate assessment session with the admitting nurse
D) History of hypertension treated with pharmacological therapy
2. A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician?
A) Serum osmolality is elevated indicating hemoconcentration.The nurse should increase IV fluid rate.
B) Serum sodium is low. The nurse should change IV fluids to normal saline.
C) Blood urea nitrogen is subnormal. The nurse should increase the protein in the client - s diet as soon as possible.
D) Serum potassium is low. The nurse should administer KCl as ordered.
3. A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can - t you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse - s greatest concern is that:
A) The client may contract an infection as a result of being exposed to large crowds at spring break
B) The client does not grasp the full impact of her illness
C) The client may require transfusion before leaving for spring break
D) The causative agent be identified and treatment begun
4. A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?
A) Hematocrit levels usually remain slightly below normalin clients with renal failure.
B) Transfusion is often begun as early as possible to prevent complications of anemia such as dyspnea and angina.
C) Anemia in renal failure is frequently caused by low serum iron and ferritin and corrected by oral iron and ferritin replacement therapy.
D) The renal secretion of erythropoiesis is decreased. The bone marrow requires erythropoietin to mature red blood cells.
5. A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim- sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104_F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells in the urine. A preliminary diagnosis of pyelonephritis was made.During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A) 'I have not been drinking six to eight glasses of water each day as the nurse had instructed.'
B) 'I - m afraid I may have something wrong with my bladder because I have been getting bladder infections frequently since I - ve been married.'
C) 'I took the Bactrim for 6 or 7 days. The burning stopped, so I saved the rest of the medication for the next time.'
D) 'I recently had the flu, which could be settling in my kidneys now.'
1. Right Answer: B
Explanation: (A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions.(D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
2. Right Answer: D
Explanation: (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately.
3. Right Answer: B
Explanation: (A) The client could contract an infection, but at this point it is not the most pertinent issue. (B) The clients statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
4. Right Answer: D
Explanation: (A) Clients in renal failure typically have very low hematocrits, often in the range of 1622%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells.(C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D)Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.
5. Right Answer: C
Explanation: (A) Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprimsulfamethoxazole, the failure to do so will not cause pyelonephritis. (B) A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. (C) The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder forthe next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. (D) There is no evidence that infection in another body system could cause pyelonephritis.
Explanation: (A) Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. (B) Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. (C) It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions.(D) A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
2. Right Answer: D
Explanation: (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydration status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicative of protein deprivation. It may also be the result of overhydration. (D)A low serum potassium potentiates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately.
3. Right Answer: B
Explanation: (A) The client could contract an infection, but at this point it is not the most pertinent issue. (B) The clients statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
4. Right Answer: D
Explanation: (A) Clients in renal failure typically have very low hematocrits, often in the range of 1622%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells.(C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D)Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.
5. Right Answer: C
Explanation: (A) Although it is important that the client drink adequate fluids while treating a bladder infection with trimethoprimsulfamethoxazole, the failure to do so will not cause pyelonephritis. (B) A stricture or abnormality may cause the progression of bladder infection to urinary tract infection, but this is rare. There is no indication in this situation that this has occurred. (C) The most common cause of pyelonephritis is improper treatment of bladder infections. The client typically feels better after several days, discontinues the medication, and saves the remainder forthe next occurrence of a bladder infection. For this reason, it is imperative to provide client education related to completion of the prescribed medication. (D) There is no evidence that infection in another body system could cause pyelonephritis.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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