NCLEX 4100 questions and answers
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's
temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The
nurse determines that the client may be experiencing which complication of a blood
transfusion?
1.Septicemia
2.Hyperkalemia
3.Circulatory overload
4.Delayed transfusion reaction ✔1
Rationale:Septicemia occurs with the transfusion of blood contaminated with
microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the
development of shock. Hyperkalemia causes weakness, paresthesias, abdominal
cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea,
chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction
can occur days to years after a transfusion. Signs include fever, mild jaundice, and a
decreased hematocrit level.
The nurse is caring for a client with meningitis and implements which transmission-
based precautions for this client?
1.Private room or cohort client
2.Personal respiratory protection device
3.Private room with negative airflow pressure
4.Mask worn by staff when the client needs to leave the room ✔1
Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease
include a private room or cohort client and use of a standard precaution mask. Private
negative airflow pressure rooms and personal respiratory protection devices are
required for clients with airborne disease such as tuberculosis. When appropriate, a
mask must be worn by the client and not the staff when the client leaves the room.
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull
fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should
contact the HCP to question which prescription?
1.Obtain daily weight.
2.Provide clear liquid intake.
3.Nasotracheal suction as needed.
4.Maintain a patent intravenous line. ✔3
Rationale:A basilar skull fracture is a type of head injury. Nasotracheal suctioning is
contraindicated in a child with a basilar skull fracture: Because of the nature of the
injury, there is a possibility that the catheter will enter the brain through the fracture,
creating a high risk of secondary infection. Fluid balance is monitored closely by daily
,weight determination, intake and output measurement, and serum osmolality
determination to detect early signs of water retention, excessive dehydration, and states
of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth)
status or restricted to clear liquids until it is determined that vomiting will not occur. An
intravenous line is maintained to administer fluids or medications, if necessary.
The nurse is reviewing the record of a child with increased intracranial pressure and
notes that the child has exhibited signs of decerebrate posturing. On assessment of the
child, the nurse expects to note which characteristic of this type of posturing?
1.Flaccid paralysis of all extremities
2.Adduction of the arms at the shoulders
3.Rigid extension and pronation of the arms and legs
4.Abnormal flexion of the upper extremities and extension and adduction of the lower
extremities ✔3
Rationale:Decerebrate (extension) posturing is characterized by the rigid extension and
pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe
decorticate (flexion) posturing.
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and
cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the
CSF analysis and determines that which results would verify the diagnosis?
1.Clear CSF, decreased pressure, and elevated protein level
2.Clear CSF, elevated protein, and decreased glucose levels
3.Cloudy CSF, elevated protein, and decreased glucose levels
4.Cloudy CSF, decreased protein, and decreased glucose levels ✔3
Rationale:Meningitis is an infectious process of the central nervous system caused by
bacteria and viruses; it may be acquired as a primary disease or as a result of
complications of neurosurgery, trauma, infection of the sinus or ears, or systemic
infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the
case of bacterial meningitis, findings usually include an elevated pressure; turbid or
cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.
An adult client was burned in an explosion. The burn initially affected the client's entire
face (anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire,
and the client ran, causing subsequent burn injuries to the posterior surface of the head
and the upper half of the posterior torso. Using the rule of nines, what would be the
extent of the burn injury?
1.18%
2.24%
3.36%
4.48% ✔3
,Rationale:According to the rule of nines, with the initial burn, the anterior half of the
head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of
both arms equals 9%. The subsequent burn included the posterior half of the head,
equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure
being performed for a third-degree circumferential arm burn. The nurse understands
that which finding is the anticipated therapeutic outcome of the escharotomy?
1.Return of distal pulses
2.Brisk bleeding from the site
3.Decreasing edema formation
4.Formation of granulation tissue ✔1
Rationale:Escharotomies are performed to relieve the compartment syndrome that can
occur when edema forms under nondistensible eschar in a circumferential third-degree
burn. The escharotomy releases the tourniquet-like compression around the arm.
Escharotomies are performed through avascular eschar to subcutaneous fat. Although
bleeding may occur from the site, it is considered a complication rather than an
anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and
elevation control the bleeding, but occasionally an artery is damaged and may require
ligation. Escharotomy does not affect the formation of edema. Formation of granulation
tissue is not the intent of an escharotomy.
The nurse is caring for a client who sustained superficial partial-thickness burns on the
anterior lower legs and anterior thorax. Which finding does the nurse expect to note
during the resuscitation/emergent phase of the burn injury?
1.Decreased heart rate
2.Increased urinary output
3.Increased blood pressure
4.Elevated hematocrit levels ✔4
Rationale:The resuscitation/emergent phase begins at the time of injury and ends with
the restoration of capillary permeability, usually at 48 to 72 hours following the injury.
During the resuscitation/emergent phase, the hematocrit level increases to above
normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of
50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return
to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and
renal perfusion and glomerular filtration are decreased, resulting in low urine output.
The burn client is prone to hypovolemia and the body attempts to compensate by
increased pulse rate and lowered blood pressure. Pulse rates are typically higher than
normal, and the blood pressure is decreased as a result of the large fluid shifts.
The nurse is administering fluids intravenously as prescribed to a client who sustained
superficial partial-thickness burn injuries of the back and legs. In evaluating the
adequacy of fluid resuscitation, the nurse understands that which assessment would
provide the most reliable indicator for determining the adequacy?
, 1.Vital signs
2.Urine output
3.Mental status
4.Peripheral pulses ✔2
Rationale:Successful or adequate fluid resuscitation in the client is signaled by stable
vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium.
However, the most reliable indicator for determining adequacy of fluid resuscitation,
especially in a client with burns, is the urine output. For an adult, the hourly urine
volume should be 30 to 50 mL.
The nurse is caring for a client following an autograft and grafting to a burn wound on
the right knee. What would the nurse anticipate to be prescribed for the client?
1.Out-of-bed activities
2.Bathroom privileges
3.Immobilization of the affected leg
4.Placing the affected leg in a dependent position ✔3
Rationale:Autografts placed over joints or on the lower extremities after surgery often
are elevated and immobilized for 3 to 7 days. This period of immobilization allows the
autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom,
and placing the grafted leg dependent would put stress on the grafted wound.
The nurse is assessing the motor and sensory function of an unconscious client. The
nurse should use which technique to test the client's peripheral response to pain?
1.Sternal rub
2.Nail bed pressure
3.Pressure on the orbital rim
4.Squeezing of the sternocleidomastoid muscle ✔2
Rationale:Nail bed pressure tests a basic motor and sensory peripheral response.
Cerebral responses to pain are tested using a sternal rub, placing upward pressure on
the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure. The nurse would
note which trend in vital signs if the intracranial pressure is rising?
1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure ✔2
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The
client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's
temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The
nurse determines that the client may be experiencing which complication of a blood
transfusion?
1.Septicemia
2.Hyperkalemia
3.Circulatory overload
4.Delayed transfusion reaction ✔1
Rationale:Septicemia occurs with the transfusion of blood contaminated with
microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the
development of shock. Hyperkalemia causes weakness, paresthesias, abdominal
cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea,
chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction
can occur days to years after a transfusion. Signs include fever, mild jaundice, and a
decreased hematocrit level.
The nurse is caring for a client with meningitis and implements which transmission-
based precautions for this client?
1.Private room or cohort client
2.Personal respiratory protection device
3.Private room with negative airflow pressure
4.Mask worn by staff when the client needs to leave the room ✔1
Rationale:Meningitis is transmitted by droplet infection. Precautions for this disease
include a private room or cohort client and use of a standard precaution mask. Private
negative airflow pressure rooms and personal respiratory protection devices are
required for clients with airborne disease such as tuberculosis. When appropriate, a
mask must be worn by the client and not the staff when the client leaves the room.
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull
fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should
contact the HCP to question which prescription?
1.Obtain daily weight.
2.Provide clear liquid intake.
3.Nasotracheal suction as needed.
4.Maintain a patent intravenous line. ✔3
Rationale:A basilar skull fracture is a type of head injury. Nasotracheal suctioning is
contraindicated in a child with a basilar skull fracture: Because of the nature of the
injury, there is a possibility that the catheter will enter the brain through the fracture,
creating a high risk of secondary infection. Fluid balance is monitored closely by daily
,weight determination, intake and output measurement, and serum osmolality
determination to detect early signs of water retention, excessive dehydration, and states
of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth)
status or restricted to clear liquids until it is determined that vomiting will not occur. An
intravenous line is maintained to administer fluids or medications, if necessary.
The nurse is reviewing the record of a child with increased intracranial pressure and
notes that the child has exhibited signs of decerebrate posturing. On assessment of the
child, the nurse expects to note which characteristic of this type of posturing?
1.Flaccid paralysis of all extremities
2.Adduction of the arms at the shoulders
3.Rigid extension and pronation of the arms and legs
4.Abnormal flexion of the upper extremities and extension and adduction of the lower
extremities ✔3
Rationale:Decerebrate (extension) posturing is characterized by the rigid extension and
pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe
decorticate (flexion) posturing.
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and
cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the
CSF analysis and determines that which results would verify the diagnosis?
1.Clear CSF, decreased pressure, and elevated protein level
2.Clear CSF, elevated protein, and decreased glucose levels
3.Cloudy CSF, elevated protein, and decreased glucose levels
4.Cloudy CSF, decreased protein, and decreased glucose levels ✔3
Rationale:Meningitis is an infectious process of the central nervous system caused by
bacteria and viruses; it may be acquired as a primary disease or as a result of
complications of neurosurgery, trauma, infection of the sinus or ears, or systemic
infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the
case of bacterial meningitis, findings usually include an elevated pressure; turbid or
cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.
An adult client was burned in an explosion. The burn initially affected the client's entire
face (anterior half of the head) and the upper half of the anterior torso, and there were
circumferential burns to the lower half of both arms. The client's clothes caught on fire,
and the client ran, causing subsequent burn injuries to the posterior surface of the head
and the upper half of the posterior torso. Using the rule of nines, what would be the
extent of the burn injury?
1.18%
2.24%
3.36%
4.48% ✔3
,Rationale:According to the rule of nines, with the initial burn, the anterior half of the
head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of
both arms equals 9%. The subsequent burn included the posterior half of the head,
equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure
being performed for a third-degree circumferential arm burn. The nurse understands
that which finding is the anticipated therapeutic outcome of the escharotomy?
1.Return of distal pulses
2.Brisk bleeding from the site
3.Decreasing edema formation
4.Formation of granulation tissue ✔1
Rationale:Escharotomies are performed to relieve the compartment syndrome that can
occur when edema forms under nondistensible eschar in a circumferential third-degree
burn. The escharotomy releases the tourniquet-like compression around the arm.
Escharotomies are performed through avascular eschar to subcutaneous fat. Although
bleeding may occur from the site, it is considered a complication rather than an
anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and
elevation control the bleeding, but occasionally an artery is damaged and may require
ligation. Escharotomy does not affect the formation of edema. Formation of granulation
tissue is not the intent of an escharotomy.
The nurse is caring for a client who sustained superficial partial-thickness burns on the
anterior lower legs and anterior thorax. Which finding does the nurse expect to note
during the resuscitation/emergent phase of the burn injury?
1.Decreased heart rate
2.Increased urinary output
3.Increased blood pressure
4.Elevated hematocrit levels ✔4
Rationale:The resuscitation/emergent phase begins at the time of injury and ends with
the restoration of capillary permeability, usually at 48 to 72 hours following the injury.
During the resuscitation/emergent phase, the hematocrit level increases to above
normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of
50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return
to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and
renal perfusion and glomerular filtration are decreased, resulting in low urine output.
The burn client is prone to hypovolemia and the body attempts to compensate by
increased pulse rate and lowered blood pressure. Pulse rates are typically higher than
normal, and the blood pressure is decreased as a result of the large fluid shifts.
The nurse is administering fluids intravenously as prescribed to a client who sustained
superficial partial-thickness burn injuries of the back and legs. In evaluating the
adequacy of fluid resuscitation, the nurse understands that which assessment would
provide the most reliable indicator for determining the adequacy?
, 1.Vital signs
2.Urine output
3.Mental status
4.Peripheral pulses ✔2
Rationale:Successful or adequate fluid resuscitation in the client is signaled by stable
vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium.
However, the most reliable indicator for determining adequacy of fluid resuscitation,
especially in a client with burns, is the urine output. For an adult, the hourly urine
volume should be 30 to 50 mL.
The nurse is caring for a client following an autograft and grafting to a burn wound on
the right knee. What would the nurse anticipate to be prescribed for the client?
1.Out-of-bed activities
2.Bathroom privileges
3.Immobilization of the affected leg
4.Placing the affected leg in a dependent position ✔3
Rationale:Autografts placed over joints or on the lower extremities after surgery often
are elevated and immobilized for 3 to 7 days. This period of immobilization allows the
autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom,
and placing the grafted leg dependent would put stress on the grafted wound.
The nurse is assessing the motor and sensory function of an unconscious client. The
nurse should use which technique to test the client's peripheral response to pain?
1.Sternal rub
2.Nail bed pressure
3.Pressure on the orbital rim
4.Squeezing of the sternocleidomastoid muscle ✔2
Rationale:Nail bed pressure tests a basic motor and sensory peripheral response.
Cerebral responses to pain are tested using a sternal rub, placing upward pressure on
the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
The nurse is caring for the client with increased intracranial pressure. The nurse would
note which trend in vital signs if the intracranial pressure is rising?
1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood
pressure
2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood
pressure
4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood
pressure ✔2
