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NCEX PN Questions of the Day 51th Edition (Adut Health)
1. A nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which of the following outcomes was noted?
A. Negative Homans’ sign
B. Active range of motion (ROM) of uninvolved joints
C. Intact skin surfaces
D. Bowel movement every 4 days
Answer: D. Bowel movement every 4 days
Rationale: Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (measurable by a negative Homans’ sign), active baseline ROM to uninvolved joints, intact skin, and a bowel movement every other day.
Test-Taking Strategy: Use the process of elimination and note the key words has not successfully met. This question can be answered by evaluating the degree of normalcy of each option. The only abnormal option is option D. A bowel movemnent every 4 days is insufficient. Remember, constipation is a known complication of immobility. Review the complications of immobility 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: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 275.
2. A nurse is caring for a client who sustained second and third degree burns on the anterior lower legs and anterior thorax. Using the Rule of Nines, the extent of the burn injury would be which of the following?
A. 31.5%
B. 36%
C. 42%
D. 45%
Answer: B. 36%
Rationale: According to the Rule of Nines, the anterior lower legs equal 18% and the anterior thorax equals 18%. This totals 36%.
Test-Taking Strategy: Knowledge regarding the Rule of Nines is required to answer this question. Remember: 9% (head and neck), 18% (right and left arms), 36% (anterior and posterior trunk), 36% (right and left legs), 1% (genitalia and perineum), equaling 99%. Review the Rule of Nines 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/Integumentary
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 1033-1034.
3. A nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The client’s carbon monoxide level is 45%. Based on this level, the nurse would anticipate which of the following signs in the client?
A. Flushing
B. Dizziness
C. Tachycardia
D. Coma
Answer: C. Tachycardia
Rationale: Carbon monoxide levels of 5% to 10% result in impaired visual acuity, levels of 11% to 20% result in flushing and headache, and levels of 21% to 30% result in nausea and impaired dexterity. Levels of 31% to 40% result in vomiting, dizziness, and syncope, levels of 41% to 50% result in tachypnea and tachycardia, and levels greater than 50% result in coma and death.
Test-Taking Strategy: Knowledge regarding the clinical manifestations of carbon monoxide poisoning is required to answer this question. Focusing on the level identified in the question will direct you to option C. Review these manifestations if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Integumentary
Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 521.
4. A client arrives at the emergency room following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which of the following would the nurse anticipate will be prescribed for the client?
A. 100% oxygen via a tight-fitting face mask
B. Oxygen via nasal cannula at 15 L
C. 100% oxygen via a tight-fitting non-rebreather face mask
D. Oxygen via nasal cannula at 10 L
Answer: C. 100% oxygen via a tight-fitting non-rebreather face mask
Rationale: If inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather mask is prescribed until carboxyhemoglobin levels fall below 15%. In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also assessed.
Test-Taking Strategy: Use the process of elimination. Recalling that 100% oxygen is required following an inhalation injury will assist in eliminating options 2 and D. From the remaining options, recall that a non-rebreather mask is preferred so that the client will not rebreathe exhaled air. Review care to the client with an inhalation injury 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/Integumentary
Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 521.
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