NGN NCLEX Prep Questions Rationales practice test with complete solutions.

The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. The nurse should suspect Your Answer: hypokalemiaCorrect Answer: hypokalemia because of the Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T waves and occasional U waves Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client's vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client's most recent serum potassium level and then contact the primary health care provider to report the findings and obtain prescriptions to treat the hypokalemic state. The nurse is preparing a client for a chest x-ray and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to this personal item? Click to highlight the correct answer from the options provided. The nurse should: (Select 1 option) Ask the client if the chain and medal can be removed during the procedure. Because: (Select 1 option) The chain and medal may have cultural significance. Rationale:Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body because of client safety and the possibility of compromising test results. Therefore, the nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. If so, the nurse should ask the client if the item can be either removed temporarily or placed on another part of the body during the procedure if appropriate. While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I have changed my mind. I don't want this surgery." Click to highlight the correct answer from the options provided. The nurse should: (Select 1 option) Cancel the surgery. Contact the surgeon. Discuss the client's concerns. Call the identified support person. Because: (Select 1 option) Client consent is required prior to any procedure. Further questions or concerns should be determined and addressed. Ethical considerations are important for a client undergoing surgery. The nursing scope of practice places limitations on how the nurse can respond. Rationale:If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client's request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client's request so that the surgeon can discuss the consequences of not having the surgery with the client. Further assessment and follow-up related to the client's request need to be done. It is the client's right to refuse treatment; however, further investigation is needed so the interventions can be tailored to specific needs. The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program?For each action, click to specify whether the action would be: Indicated: an action that the nurse should take to resolve the problem Non-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problem Contraindicated: an action that could harm the client and should not be taken Collect identifying patient information Contraindicated Note the mental status of the client Non-essential Note primary and secondary diagnoses of clients affected Indicated Note the type of IV catheter used Indicated Note the type of IV site dressings being used Indicated Note the medication types being infused Non-essential Note frequency of assessments of IV sites Indicated Note the expected duration of the IV site Non-essential Note care procedures to the IV site Indicated Note frequency of changing IV sites Indicated Rationale:Quality improvement, also known as performance improvement, focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used. Collecting identifying client information is contraindicated because of confidentiality and is unnecessary in this quality improvement effort. Noting the mental status of the clients can be done but is not likely to address the The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the correct missing information by choosing from the lists of options in the drop-down menus. The test result is Your Answer: Abnormal Correct Answer: Abnormal because Your Answer: The time for color to return is prolonge Correct Answer: The time for color to return is prolonged Rationale:Failure to determine the presence of adequate collateral circulation before drawing an arterial blood gas specimen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Another site needs to be selected for the arterial puncture, and the primary health care provider needs to be notified of the finding. The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client's vital signs. Click to highlight the current finding(s) that would be essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a finding, click the finding again. 30 min ago: BP= 142/78 HR= 98 RR= 14 Temp= 37.2 C O2 sat= 95% 3L NC Current: BP= 95/54 (F/U correct) HR= 118 (F/U correct) RR= 18 Temp= 36.8 C O2 sat= 91% 3L NC (F/U correct) Rationale:Some of the client's vital signs are showing a significant change, particularly the blood pressure, heart rate, and oxygen saturation levels. The nurse should first compare the current vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about how much of a change has occurred in these parameters. The nurse should quickly consider the following when determining the next action: (1) What is the client's condition? Is the client responding to stimuli? (2) Does the oxygen saturation increase if the client deep breathes? (3) Is the equipment working properly? (4) Is the correct equipment being used? (5) Is there a condition or procedure in the client's history that can be attributed to this change? (6) Are there environmental factors that could influence the change in the client's vital signs? (7) Does this change in the client necessitate contacting the surgeon? Given the significant changes from the baseline vital signs, and after checking the client and equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding such as drainage on the dressing, bloody output in a surgical drain, or swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status. A client has been diagnosed with chronic kidney disease. The nurse anticipates specific dietary prescriptions due to the risks associated with chronic kidney disease. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. The nurse should note the client is Your Answer: On a fluid restriction Correct Answer: On a fluid restriction because Your Answer: Of the risk of hypervolemia Correct Answer: of the risk of hypervolemia To relieve the thirst, the nurse should instruct the client to Your Answer: Chew gum Correct Answer: Chew gum because Your Answer: it doesn't contribute to hypervolemia Correct Answer: it doesn't contribute to hypervolemia Rationale:The client with chronic kidney disease may be placed on fluid restriction because of decreased renal function and glomerular filtration rate, resulting in fluid volume excess. To allow the kidneys to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, freezing fluids so they take longer to consume, adding lemon juice to allowed water to make it more refreshing, and gargling with refrigerated mouthwash. A client with a peripherally inserted central catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do?For each action, click to specify whether the action would be:Indicated: an action that the nurse should take to resolve the problemNon-essential: an action that the nurse could take without harming the client, but the action would not be likely to address the problemContraindicated: an action that could harm the client and should not be taken Action Assess for fever Non-essential Assess for chest pain Indicated Assess for cyanosis Indicated Turn the client to the left side Indicated Position the client so the feet are lower than the head Contraindicated Administer oxygen Indicated Place the client on continuous vital sign monitoring Indicated Notify the primary health care provider Indicated Rationale:When a client has any type of central venous catheter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism. Signs and symptoms that this complication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia, and the nurse would assess for these findings. If this occurs, the nurse should clamp the catheter, place the client on the left side with the head lower than the feet (not the feet lower than the head) to trap the embolism in the right atrium of the heart, administer oxygen, and notify the primary health care provider. Continuous vital sign monitoring should also be done to note for changes in the client's condition. There is no reason for assessing for a fever at this time. The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfusion. The nurse suspects a transfusion reaction based on clinical presentation. Based on this scenario, select the initial clinical findings for each suspected condition Acute hemolytic reaction 1 Allergic reaction 3-4-5 Fluid volume overload 2 Back pain(1) Difficulty breathing(2) Rash(3) Urticaria(4) Pruritis(5) Rationale:There are different types of blood transfusion reactions, including fluid volume overload, allergic reaction, and acute hemolytic reaction. In general, signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. An acute hemolytic reaction is usually characterized by back pain initially. An allergic reaction is manifested by rash, urticarial, and pruritis as initial signs. Fluid volume overload often is noted by difficulty breathing in the early phase. The nurse is assessing an infant with clubfoot who is in a cast. The nurse notes the following clinical findings on assessment.Vital signs: Blood pressure 90/60 mm Hg Heart rate 112 beats per minute Respirations 24 breaths per minute Oxygen saturation 98% on room air Temperature 36.4° C (97.5° F) Musculoskeletal findings : Tissue distal to the cast is pale and edematous.The infant shows signs of pain with passive movement. Which actions should the nurse take? Select all that apply. 1.Notify the surgeon 2.Administer topical pain medication 3.Administer anticoagulant medication 4.Contact the physical therapy department 5.Assess distal pulses on bilateral extremities 1 & 5 Rationale:Compartment syndrome is a condition in which pressure increases in a confined anatomical space, leading to decreased blood flow, ischemia, and dysfunction of these tissues. This complication can occur with casts. Signs of this complication include unrelieved or increased pain in the limb; pale, dusky, or edematous tissue distal to the involved area; pain with passive movement; loss of sensation (paresthesia); and pulselessness (a late sign). In this scenario, the nurse should assess the distal pulses on bilateral extremities. Noting a difference between the 2 extremities is helpful in determining the presence of compartment syndrome. The nurse should contact the surgeon immediately if signs of neurovascular impairment are noted in a child with a cast or brace because of the risk of tissue ischemia and necrosis. Administering topical pain medication is not helpful because of the severity of the pain, and relief of the pressure is the priority and ultimately will relieve the pain. Administering anticoagulant medication does not address the problem of the pressure from the tight compartment. Contacting the physical therapy department is unnecessary and does not help to address this complication. The nurse is working in a long-term care facility that has a "no restraint policy." An assigned client is disoriented and unsteady and continually attempts to climb out of bed. Which interventions and supporting rationales are appropriate in this scenario? Fill in the correct missing information by choosing from the lists of options in the drop-down menus. The nurse should Your Answer: Implement other safety strategies Correct Answer: Implement other safety strategies due to Your Answer: The risk for further injury with restraints Correct Answer: The risk for further injury with restraints Type in 3 safety strategies the nurse should implement: Any 3 of the following would be correct: Orienting the client and family to the surroundings Explaining all procedures Encouraging family and friends to stay Assigning confused or disoriented clients to a room near the nurses' station Providing appropriate stimuli to the client Maintaining toileting routines Eliminating bothersome treatments Using relaxation techniques Instituting an ambulation schedule Rationale:Many facilities implement a "no restraint policy," which requires health care workers to implement other safety strategies for clients who pose a risk for falls. These strategies include orienting the client and family to the surroundings; explaining all procedures and treatments to the client and family; encouraging family and friends to stay with the client as appropriate and using sitters for clients who need supervision; assigning confused and disoriented clients to rooms near the nurses' station; providing appropriate visual and auditory stimuli to the client, such as a night-light, clock, calendar, television, or radio; maintaining toileting routines; eliminating bothersome treatments, such as tube feedings, as soon as possible; evaluating all medications that the client is receiving; using relaxation techniques with the client; and instituting exercise and ambulation schedules as the client's condition allows. Some agencies are instituting certain policies, such as hourly rounding, to ensure client safety. With hourly rounding, nurses and assistive personnel are required to check the client to address the 5 Ps—p The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. In considering the child's developmental stage, the nurse should determine that this is an expected finding. Using Freud's psychosexual stages of development, identify the behaviors associated with the various stages that can be taught to the mother to alleviate her concerns. Select the behaviors that associate with Freud's psychosexual stages of development. Oral Correct Answer:4. Mouth-sucking and swallowing Anal Correct Answer:3. Withholding or expelling feces Phallic Correct Answer:1. Masturbation Latent Correct Answer:5. Little to no sexual motivation present Genital Correct Answer:2. Sexual intercourse Rationale:According to Freud's psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining genitalia, masturbating, and expressing interest in sexual concerns. The oral phase is associated with mouth-sucking and swallowing, the anal with withholding or expelling feces, the latent with little to no sexual motivation, and genital with sexual intercourse. The nurse should alleviate the mother's concern by telling the mother that this behavior is normal.