NCLEX- RN Review Question Assignment #2
Madison Brinsley 1/30/2018
1. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days
ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse
should first:
a. Assess for changes in the vital signs.
b. Draw an arterial blood gas.
c. Evaluate heart sounds with the client leaning forward.
d. Obtain a 12-lead electrocardiogram.
Rationale: (a) The nurse should first obtain vital signs as changes in the vital signs will reflect the
severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart
rate, and increase in respirations. (Billings & Hensel, 2017, p. 340)
2. The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor.
The nurse should first:
a. Administer atropine 0.5 mg IV push.
b. Auscultate for abnormal heart sounds.
c. Prepare for transcutaneous pacing.
d. Take the client’s blood pressure.
Rationale: (d) The nurse should first assess the client’s tolerance to the drop in heart rate by
checking the blood pressure and level of consciousness and determine if atropine is needed.
(Billings & Hensel, 2017, p. 341)
3. The nurse is obtaining consent for a bone marrow aspiration. Which actions should the
nurse take? SATA:
a. Witness the client signing the consent form.
b. Evaluate that the client understands the procedure.
c. Explain the risks of the procedure to the client.
d. Verify that the client is signing the consent form of his or her own free will.
e. Determine that the client understands postprocedure care.
Rationale: (a, b, d, e) The nurse can serve as a witness for consent for the procedures. The
nurse also ascertains whether the client has an understanding that is consistent with the
procedure listed on the form, determines that the client is signing the consent of his or her own
free will, and determines that the client understands postprocedure care. The nurse’s role does
not include explaining the risks of the procedure; that responsibility belongs to the person who
is to perform the procedure, such as the HCP. (Billings & Hensel, 2017, p. 400)
4. Which mental status change may occur when a client with pneumonia is first
experiencing hypoxia?
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, a. Coma
b. Apathy
c. Irritability
d. Depression
Rationale: (C) Clients who are experiencing hypoxia characteristically exhibit irritability,
restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more
pronounced, the client may become confused and combative. Coma is a late clinical
manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia. (Billings &
Hensel, 2017, p. 429)
5. A nurse is assessing a client with chronic emphysema. Which finding requires immediate
intervention?
a. Using pursed-lip breathing and prolonged expiration
b. Circumoral cyanosis
c. Crackles auscultated posteriorly halfway up the left lung
d. Appearance of a “barrel chest”
Rationale: (c) Crackles auscultated in the lung field indicate excessive fluid, a problem that
requires immediate intervention. Pursed-lip breathing and a prolonged expiratory phase,
circumoral cyanosis, and increased anterior posterior diameter of the chest are not unusual
findings in emphysema patients. (Billings & Hensel, 2017, p. 431)
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Madison Brinsley 1/30/2018
1. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days
ago. Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse
should first:
a. Assess for changes in the vital signs.
b. Draw an arterial blood gas.
c. Evaluate heart sounds with the client leaning forward.
d. Obtain a 12-lead electrocardiogram.
Rationale: (a) The nurse should first obtain vital signs as changes in the vital signs will reflect the
severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart
rate, and increase in respirations. (Billings & Hensel, 2017, p. 340)
2. The nurse notices that a client’s heart rate decreases from 63 to 50 bpm on the monitor.
The nurse should first:
a. Administer atropine 0.5 mg IV push.
b. Auscultate for abnormal heart sounds.
c. Prepare for transcutaneous pacing.
d. Take the client’s blood pressure.
Rationale: (d) The nurse should first assess the client’s tolerance to the drop in heart rate by
checking the blood pressure and level of consciousness and determine if atropine is needed.
(Billings & Hensel, 2017, p. 341)
3. The nurse is obtaining consent for a bone marrow aspiration. Which actions should the
nurse take? SATA:
a. Witness the client signing the consent form.
b. Evaluate that the client understands the procedure.
c. Explain the risks of the procedure to the client.
d. Verify that the client is signing the consent form of his or her own free will.
e. Determine that the client understands postprocedure care.
Rationale: (a, b, d, e) The nurse can serve as a witness for consent for the procedures. The
nurse also ascertains whether the client has an understanding that is consistent with the
procedure listed on the form, determines that the client is signing the consent of his or her own
free will, and determines that the client understands postprocedure care. The nurse’s role does
not include explaining the risks of the procedure; that responsibility belongs to the person who
is to perform the procedure, such as the HCP. (Billings & Hensel, 2017, p. 400)
4. Which mental status change may occur when a client with pneumonia is first
experiencing hypoxia?
This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00
https://www.coursehero.com/file/34549824/NCLEX-2docx/
, a. Coma
b. Apathy
c. Irritability
d. Depression
Rationale: (C) Clients who are experiencing hypoxia characteristically exhibit irritability,
restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more
pronounced, the client may become confused and combative. Coma is a late clinical
manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia. (Billings &
Hensel, 2017, p. 429)
5. A nurse is assessing a client with chronic emphysema. Which finding requires immediate
intervention?
a. Using pursed-lip breathing and prolonged expiration
b. Circumoral cyanosis
c. Crackles auscultated posteriorly halfway up the left lung
d. Appearance of a “barrel chest”
Rationale: (c) Crackles auscultated in the lung field indicate excessive fluid, a problem that
requires immediate intervention. Pursed-lip breathing and a prolonged expiratory phase,
circumoral cyanosis, and increased anterior posterior diameter of the chest are not unusual
findings in emphysema patients. (Billings & Hensel, 2017, p. 431)
This study source was downloaded by 100000869267694 from CourseHero.com on 07-24-2023 01:09:44 GMT -05:00
https://www.coursehero.com/file/34549824/NCLEX-2docx/
