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
