Nursing Examination Quiz with Answer and Rationale 2019 / 2020 / 2021 20th Edition
Nursing Examination Quiz with Answer and Rationale 2019 / 2020 / 2021 20th Edition
1. A nurse is caring for a client being treated for a fat embolus after multiple fractures. Which of the following data would the nurse determine as the most favorable indication of resolution of the fat embolus?
A. Arterial oxygen level of 78 mm Hg
B. Minimal dyspnea
C. Clear chest x-ray
D. Oxygen saturation of 85%
Answer: C. Clear chest x-ray
Rationale: A clear chest x-ray is a favorable indicator that a fat embolus is resolving. When fat embolism occurs, there is a “snowstorm” appearance to the chest x-ray. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.
Test-Taking Strategy: Note the key words most favorable. Knowledge of normal baseline respiratory values will assist in answering this question. Knowing that the arterial oxygen and oxygen saturation levels are below normal helps you to eliminate options 1 and D. Dyspnea, even at a minimal level, is not normal and can be eliminated also. A clear chest x-ray is a normal finding, and is the answer to the question as stated. Review this complication of a fracture if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Musculoskeletal
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 629.
2. A client has undergone a fasciotomy to treat compartment syndrome of the leg. The nurse would expect that which type of wound care will be prescribed for the fasciotomy site?
A. Dry sterile dressings
B. Moist sterile saline dressings
C. Hydrocolloid dressings
D. One-half strength Betadine dressings
Answer: B. Moist sterile saline dressings
Rationale: The fasciotomy site is not sutured, but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Options 1, 3, and 4 are incorrect.
Test-Taking Strategy: This question can be answered by knowing what a fasciotomy involves and knowing the basics of wound care. With fasciotomy, the skin is not sutured closed, but left open for pressure relief. Moist tissue needs to remain moist, which eliminates option A. A hydrocolloid dressing is not indicated for use with clean, open incisions, which eliminates option C. The incision is clean, not dirty, so there should be no reason to require Betadine. Knowing that Betadine can be irritating to normal tissues is an additional reason to choose option 2 over option D. Review postprocedure care following a fasciotomy if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Musculoskeletal
Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 143-144.
3. A nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client reports which early symptom of compartment syndrome?
A. Pain that is relieved only by a narcotic analgesic
B. Pain that increases when the arm is dependent
C. Cold, bluish colored fingers
D. Numbness and tingling in the fingers
Answer: D. Numbness and tingling in the fingers
Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.
Test-Taking Strategy: Note the key word early. Because cyanosis is a late sign, option 3 is eliminated first. Knowing that compartment syndrome is characterized by insufficient circulation and ischemia secondary to pressure, you would look for symptoms that are consistent with pressure. Pain would be increased with elevation rather than dependency, so option 2 can be eliminated also. Because the pain of ischemia is generally not relieved with analgesics, this cannot be an early symptom either. This leaves numbness and tingling as the answer. Review the early signs of compartment syndrome if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Musculoskeletal
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 824.
4. An older client is brought to the emergency room via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse would expect to note which of the following on inspection of the client’s leg?
A. Lengthening, adduction, and external rotation
B. Shortening, abduction, and internal rotation
C. Shortening, adduction, and external rotation
D. Lengthening, abduction, and internal rotation
Answer: C. Shortening, adduction, and external rotation
Rationale: Typical signs and symptoms following femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain, or pain on the medial side of the knee. Moving the fractured extremity significantly increases the pain.
Test-Taking Strategy: Knowledge of basic signs and symptoms of hip fracture is necessary to answer this question. Remember, shortening of the affected leg, adduction, and external rotation would occur. Review the signs of a femoral neck fracture if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Musculoskeletal
References:
- Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1678.
- Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 831.
5. A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client:
A. Holds the walker using the handgrips
B. Leans forward slightly when advancing the walker
C. Advances the walker with reciprocal motion
D. Supports body weight on the hands while advancing the weaker leg
Answer: C. Advances the walker with reciprocal motion
Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus, the client would not be supporting the weaker leg with the walker during ambulation.
Test-Taking Strategy: Note the key word incorrectly. These words indicate a false response question and that you need to select the incorrect client action. Holding the walker using the handgrips is an obvious correct action, and is eliminated first. The client must lean forward slightly in order to move the walker forward, so this option is eliminated as well. Reciprocal motion is moving one leg and the opposite arm at the same time. If the client were trying to do this with a walker, the client would be twisting the walker from side to side as it advances. This would be incorrect, and is therefore the answer to the question. Review the principles related to the use of a walker if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Adult Health/Musculoskeletal
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 793, 805.
Thank you for your attention with reading our article Nursing Quiz NCLEX About Pharmacology with Answer and Rationale 18th Edition. Thanks for your participation, like and share if this is usefull.
0 Response to "Nursing Examination Quiz with Answer and Rationale 2019 / 2020 / 2021 20th Edition"
Post a Comment