NCLEX-RN CRITICAL
CARE 2021
a - The nurse is providing postprocedure care to a client who had a cardiac catheterization. The
client begins to manifest signs and symptoms associated with embolization. Which action
should the nurse take?
a. Notify the primary healthcare provider immediately
b. Apply a warm, moist compress to the incision site
c. Increase the intravenous fluid rate by 20 mL/hr
d. Monitor vital signs more frequently
b - A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to
the scene and determines that the person is in cardiopulmonary arrest. What should the nurse
do first?
a. Feel for a pulse
b. Begin chest compressions
c. Leave to call for assistance
d. Perform the abdominal thrust maneuver
d - A client reports left-sided chest pain after playing racquetball. The client is hospitalized and
diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse
expects to identify which finding?
,a. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
c - A client is admitted to the hospital with partial- and full-thickness burns of the chest and face
sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?
a. Loss of skin integrity caused by the burns
b. Potential infection as a result of the burn injury
c. Inadequate gas exchange caused by smoke inhalation
d. Decreased fluid volume because of the depth of the burns
b - During the first 48 hours after a client has sustained a thermal injury, which conditions should
the nurse assess for?
a. Hypokalemia and hyponatremia
b. Hyperkalemia and hyponatremia
c. Hypokalemia and hypernatremia
d. Hyperkalemia and hypernatremia
,a - A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are
equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds.
Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this
rhythm?
a. Normal sinus rhythm
b. Sinus tachycardia
c. Sinus bradycardia
d. Sinus arrhythmia
b - The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority
concern of the nurse when caring for this client?
a. Fluid volume
b. Skin integrity
c. Physical mobility
d. Urinary elimination
c - A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for
breath, and reports right-sided chest pain. What should the nurse do first?
a. Obtain vital signs
b. Initiate a cardiac arrest code
c. Administer oxygen using a face mask
, d. Encourage the use of an incentive spirometer
c - A nurse is caring for a client with severe burns. The nurse determines that this client is at risk
for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?
a. Decreased rate of glomerular filtration
b. Excessive blood loss through the burned tissues
c. Plasma proteins moving out of the intravascular compartment
d. Sodium retention occurring as a result of the aldosterone mechanism
a - The nurse is caring for a client with burns and reviews the client's laboratory results: blood
urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum
potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL
(74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?
a. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
d - A nurse is caring for a client who experienced serious burns in a fire. Which relationship
between a client's burned body surface area and fluid loss should the nurse consider when
evaluating fluid loss in a client with burns?
a. Equal
CARE 2021
a - The nurse is providing postprocedure care to a client who had a cardiac catheterization. The
client begins to manifest signs and symptoms associated with embolization. Which action
should the nurse take?
a. Notify the primary healthcare provider immediately
b. Apply a warm, moist compress to the incision site
c. Increase the intravenous fluid rate by 20 mL/hr
d. Monitor vital signs more frequently
b - A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to
the scene and determines that the person is in cardiopulmonary arrest. What should the nurse
do first?
a. Feel for a pulse
b. Begin chest compressions
c. Leave to call for assistance
d. Perform the abdominal thrust maneuver
d - A client reports left-sided chest pain after playing racquetball. The client is hospitalized and
diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse
expects to identify which finding?
,a. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
c - A client is admitted to the hospital with partial- and full-thickness burns of the chest and face
sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?
a. Loss of skin integrity caused by the burns
b. Potential infection as a result of the burn injury
c. Inadequate gas exchange caused by smoke inhalation
d. Decreased fluid volume because of the depth of the burns
b - During the first 48 hours after a client has sustained a thermal injury, which conditions should
the nurse assess for?
a. Hypokalemia and hyponatremia
b. Hyperkalemia and hyponatremia
c. Hypokalemia and hypernatremia
d. Hyperkalemia and hypernatremia
,a - A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are
equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds.
Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this
rhythm?
a. Normal sinus rhythm
b. Sinus tachycardia
c. Sinus bradycardia
d. Sinus arrhythmia
b - The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority
concern of the nurse when caring for this client?
a. Fluid volume
b. Skin integrity
c. Physical mobility
d. Urinary elimination
c - A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for
breath, and reports right-sided chest pain. What should the nurse do first?
a. Obtain vital signs
b. Initiate a cardiac arrest code
c. Administer oxygen using a face mask
, d. Encourage the use of an incentive spirometer
c - A nurse is caring for a client with severe burns. The nurse determines that this client is at risk
for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?
a. Decreased rate of glomerular filtration
b. Excessive blood loss through the burned tissues
c. Plasma proteins moving out of the intravascular compartment
d. Sodium retention occurring as a result of the aldosterone mechanism
a - The nurse is caring for a client with burns and reviews the client's laboratory results: blood
urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum
potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL
(74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?
a. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
d - A nurse is caring for a client who experienced serious burns in a fire. Which relationship
between a client's burned body surface area and fluid loss should the nurse consider when
evaluating fluid loss in a client with burns?
a. Equal
