Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse is assisting a physician with insertion of an endotracheal tube (ETT). The nurse should plan to assure that which of the following is done as a final measure to determine correct tube placement?
A. Hyperoxygenate the client
B. Listen for bilateral breath sounds
C. Tape the tube securely in place
D. Verify placement by chest x-ray
Answer: D. Verify placement by chest x-ray
Rationale: The final measure to determine ETT placement is to verify by chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement.
Test-Taking Strategy: The key words in the question are final measure and correct tube placement. These words tell you that you are looking for a correct item, and also imply a time sequence. Knowing that the client is hyperoxygenated before and immediately after insertion, you would eliminate option A. Option 2 is eliminated next because it is the initial means used to verify placement, not the final one. Option 3 is done before option 4 to avoid tube displacement before or during the x-ray. Review the procedures for verifying correct ETT placement if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Respiratory
References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1883.
deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 479.
2. An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of a nursing diagnosis of decreased cardiac output related to possible dysrhythmias as evidenced by dyspnea and a syncopal episode. The nurse plans to take which most important action in the care of the client?
A. Measure blood pressure every 4 hours
B. Monitor oxygen saturation levels
C. Check capillary refill at least once per shift
D. Place the client on a cardiac monitor
Answer: D. Place the client on a cardiac monitor
Rationale: The client with decreased cardiac output and possible dysrhythmias should be placed on continuous cardiac monitoring so myocardial perfusion can be most accurately assessed. Other cardiovascular assessments should be made at least every 2 hours initially.
Test-Taking Strategy: Focus on the data provided in the question and note the key words possible dysrhythmias. These words along with the words “most important action” limit the choices to options 2 or D. Since option 4 is a more direct measurement about cardiovascular status, it is chosen over option 2 (which in the absence of cardiac monitoring would be a reasonable choice). Review appropriate goals for the nursing diagnosis of decreased cardiac output 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/Cardiovascular
References: Gulanick, M., Myers, J., Klopp, A., Gradishar, D., Galanes, S., & Puzas, M. (2003). Nursing care plans: Nursing diagnosis and intervention (5th ed.). St. Louis: Mosby, p. 30.
Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1770.
3. A nurse is planning adaptations needed for activities of daily living for the client with cardiac disease. The nurse would incorporate which of the following in discussions with the client?
A. Consume 1 to 2 ounces of liquor each night to promote vasodilation
B. Try to engage in vigorous activity to strengthen cardiac reserve
C. Consume adequate daily fiber to prevent straining and constipation
D. Increase fluid intake to 3000 mL per day to promote renal perfusion
Answer: C. Consume adequate daily fiber to prevent straining and constipation
Rationale: Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Increasing fluid intake to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the effects of cardiac disease to answer the question. Focusing on the client’s diagnosis will assist in eliminating options 1 and D. From the remaining options, noting the word “vigorous” in option 2 will assist in eliminating this option. Review care to the client with cardiac disease if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Cardiovascular
Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: health and illness perspectives (7th ed.). St. Louis: Mosby, p. 725.
4. A nurse is assigned to care for a client with a diagnosis of hepatic encephalopathy. The nurse is preparing to administer medications to the client expecting that which medication is prescribed?
A. Magnesium hydroxide (Milk of Magnesia)
B. Phenolphthalein (Ex-Lax)
C. Psyllium hydrophilic mucilloid (Metamucil)
D. Lactulose syrup (Chronulac)
Answer: D. Lactulose syrup (Chronulac)
Rationale: Lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH, which aids the conversion of ammonia in the colon to the ammonium ion, which is poorly absorbed. Magnesium hydroxide is a saline laxative, while phenolphthalein is a stimulant laxative. Psyllium hydrophilic mucilloid is a bulk laxative.
Test-Taking Strategy: To answer this question accurately, it is necessary to know the pathophysiology related to hepatic encephalopathy, the specific effects of prescribed medications, and the benefits of use in the client with impaired liver function. Remember, lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. Review care to the client with hepatic encephalopathy if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 612.
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