Nclex questions 4100 exam 3
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1. The nurse is preparing to care 4
for a client who has returned Rationale:
to the nursing unit following After cardiac catheterization, the extremity into which
cardiac catheterization performed the catheter was inserted is kept straight for 4 to 6
through the femoral vessel. The hours. The client is maintained on bed rest for 4 to 6
nurse checks the health care hours (time for bed rest may vary depending on the
provider's (HCP's) prescription and HCP's preference and on whether a vascular closure
plans to allow which client posi- device was used) and the client may turn from side to
tion or activity following the proce- side. The head is elevated no more than 30 degrees
dure? (although some HCPs prefer a lower position or the flat
position) until hemostasis is adequately achieved.
1. Bed rest in high Fowler's posi-
tion
2. Bed rest with bathroom privi-
leges only
3.Bed rest with head elevation at
60 degrees
4. Bed rest with head elevation no
greater than 30 degrees
2. The nurse is assessing the func- 3, 4, 5, 6
tioning of a chest tube drainage Rationale:
system in a client who has just re-The bubbling of water in the water seal chamber indi-
turned from the recovery room fol- cates air drainage from the client and usually is seen
lowing a thoracotomy with wedge when intrathoracic pressure is higher than atmospheric
resection. Which are the expect- pressure, and may occur during exhalation, coughing,
ed assessment findings? Select all or sneezing. Excessive bubbling in the water seal cham-
that apply. ber may indicate an air leak, an unexpected finding.
Fluctuation of water in the tube in the water seal cham-
ber during inhalation and exhalation is expected. An
1. Excessive bubbling in the water
absence of fluctuation may indicate that the chest tube
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seal chamber is obstructed or that the lung has reexpanded and that
2. Vigorous bubbling in the suction no more air is leaking into the pleural space. Gentle
control chamber (not vigorous) bubbling should be noted in the suction
3. Drainage system maintained be- control chamber. A total of 50 mL of drainage is not
low the client's chest excessive in a client returning to the nursing unit from
4. 50 mL of drainage in the the recovery room. Drainage that is more than 70 to 100
drainage collection chamber mL/hour is considered excessive and requires notifica-
5. Occlusive dressing in place over tion of the health care provider. The chest tube insertion
the chest tube insertion site site is covered with an occlusive (airtight) dressing to
6. Fluctuation of water in the tube prevent air from entering the pleural space. Positioning
in the water seal chamber during the drainage system below the client's chest allows
inhalation and exhalation gravity to drain the pleural space.
3. The nurse is assisting a health care 4
provider with the removal of a Rationale:
chest tube. The nurse should in- When the chest tube is removed, the client is asked
struct the client to take which ac- to perform the Valsalva maneuver (take a deep breath,
tion? exhale, and bear down). The tube is quickly withdrawn,
and an airtight dressing is taped in place. An alternative
1. Stay very still. instruction is to ask the client to take a deep breath and
2. Exhale very quickly. hold the breath while the tube is removed.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver.
4. The nurse caring for a client with 2
a pneumothorax and who has had Rationale:
a chest tube inserted notes contin- Fluctuation with inspiration and expiration, not con-
uous gentle bubbling in the water tinuous bubbling, should be noted in the water seal
seal chamber. What action is most chamber. Intermittent bubbling may be noted if the
appropriate? client has a known pneumothorax, but this should de-
crease as time goes on and as the pneumothorax be-
gins to resolve. Therefore, the nurse should check for
1. Do nothing, because this is an
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expected finding. an air leak. If a wet chest drainage system is used, bub-
2. Check for an air leak, because bling would be continuous in the suction control cham-
the bubbling should be intermit- ber and not intermittent. In a dry system, there is no
tent. bubbling. Increasing the suction pressure only increas-
3. Increase the suction pressure so es the rate of evaporation of water in the drainage sys-
that the bubbling becomes vigor- tem; in addition, increasing the suction can be harmful
ous. and is not done without a specific prescription to do
4. Clamp the chest tube and notify so if using a wet system. Dry systems will allow for only
the health care provider immedi- a certain amount of suction to be applied; an orange
ately. bellow will appear in the suction window, indicating
that the proper amount of suction has been applied.
Chest tubes should be clamped only with a health care
provider's prescription.
5. The nurse is caring for a client 1, 3, 6
with lung cancer and bone metas- Rationale:
tasis. What signs and symptoms Oncological emergencies include sepsis, disseminated
would the nurse recognize as in- intravascular coagulation, syndrome of inappropriate
dications of a possible oncologicalantidiuretic hormone, spinal cord compression, hyper-
emergency? Select all that apply. calcemia, superior vena cava syndrome, and tumor lysis
syndrome. Blockage of blood flow to the venous system
of the head resulting in facial edema is a sign of supe-
1. Facial edema in the morning
rior vena cava syndrome. A serum calcium level of 12
2.Weight loss of 20 lb (9 kg) in 1
mg/dL (3.0 mmol/L) indicates hypercalcemia. Numb-
month
ness and tingling of the lower extremities could be a
3. Serum calcium level of 12 mg/dL
sign of spinal cord compression. Mild hypokalemia and
(3.0 mmol/L)
weight loss are not oncological emergencies. A sodium
4. Serum sodium level of 136
level of 136 mg/dL (136 mmol/L) is a normal level.
mg/dL (136 mmol/L)
5. Serum potassium level of 3.4
mg/dL (3.4 mmol/L)
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6. Numbness and tingling of the
lower extremities
6. The nurse is assessing the respi- 4
ratory status of a client who has Rationale:
suffered a fractured rib. The nurse Rib fractures result from a blunt injury or a fall. Typi-
should expect to note which find- cal signs and symptoms include pain and tenderness
ing? localized at the fracture site that is exacerbated by in-
spiration and palpation, shallow respirations, splinting
or guarding the chest protectively to minimize chest
1. Slow, deep respirations
movement, and possible bruising at the fracture site.
2. Rapid, deep respirations
Paradoxical respirations are seen with flail chest
3. Paradoxical respirations
4. Pain, especially with inspiration
7. A client with a chest injury has 3
suffered flail chest. The nurse as-
sesses the client for which most Flail chest results from multiple rib fractures. This re-
distinctive sign of flail chest? sults in a "floating" section of ribs. Because this section
is unattached to the rest of the bony rib cage, this
segment results in paradoxical chest movement. This
1. Cyanosis means that the force of inspiration pulls the fractured
2.Hypotension segment inward, while the rest of the chest expands.
3. Paradoxical chest movement Similarly, during exhalation, the segment balloons out-
4. Dyspnea, especially on exhala- ward while the rest of the chest moves inward. This is a
tion characteristic sign of flail chest.
8. The nurse is assessing a client 4
with multiple trauma who is at
risk for developing acute respira- The earliest detectable sign of acute respiratory distress
tory distress syndrome. The nurse syndrome is an increased respiratory rate, which can
should assess for which earliest begin from 1 to 96 hours after the initial insult to
sign of acute respiratory distress the body. This is followed by increasing dyspnea, air
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1. The nurse is preparing to care 4
for a client who has returned Rationale:
to the nursing unit following After cardiac catheterization, the extremity into which
cardiac catheterization performed the catheter was inserted is kept straight for 4 to 6
through the femoral vessel. The hours. The client is maintained on bed rest for 4 to 6
nurse checks the health care hours (time for bed rest may vary depending on the
provider's (HCP's) prescription and HCP's preference and on whether a vascular closure
plans to allow which client posi- device was used) and the client may turn from side to
tion or activity following the proce- side. The head is elevated no more than 30 degrees
dure? (although some HCPs prefer a lower position or the flat
position) until hemostasis is adequately achieved.
1. Bed rest in high Fowler's posi-
tion
2. Bed rest with bathroom privi-
leges only
3.Bed rest with head elevation at
60 degrees
4. Bed rest with head elevation no
greater than 30 degrees
2. The nurse is assessing the func- 3, 4, 5, 6
tioning of a chest tube drainage Rationale:
system in a client who has just re-The bubbling of water in the water seal chamber indi-
turned from the recovery room fol- cates air drainage from the client and usually is seen
lowing a thoracotomy with wedge when intrathoracic pressure is higher than atmospheric
resection. Which are the expect- pressure, and may occur during exhalation, coughing,
ed assessment findings? Select all or sneezing. Excessive bubbling in the water seal cham-
that apply. ber may indicate an air leak, an unexpected finding.
Fluctuation of water in the tube in the water seal cham-
ber during inhalation and exhalation is expected. An
1. Excessive bubbling in the water
absence of fluctuation may indicate that the chest tube
, Nclex questions 4100 exam 3
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seal chamber is obstructed or that the lung has reexpanded and that
2. Vigorous bubbling in the suction no more air is leaking into the pleural space. Gentle
control chamber (not vigorous) bubbling should be noted in the suction
3. Drainage system maintained be- control chamber. A total of 50 mL of drainage is not
low the client's chest excessive in a client returning to the nursing unit from
4. 50 mL of drainage in the the recovery room. Drainage that is more than 70 to 100
drainage collection chamber mL/hour is considered excessive and requires notifica-
5. Occlusive dressing in place over tion of the health care provider. The chest tube insertion
the chest tube insertion site site is covered with an occlusive (airtight) dressing to
6. Fluctuation of water in the tube prevent air from entering the pleural space. Positioning
in the water seal chamber during the drainage system below the client's chest allows
inhalation and exhalation gravity to drain the pleural space.
3. The nurse is assisting a health care 4
provider with the removal of a Rationale:
chest tube. The nurse should in- When the chest tube is removed, the client is asked
struct the client to take which ac- to perform the Valsalva maneuver (take a deep breath,
tion? exhale, and bear down). The tube is quickly withdrawn,
and an airtight dressing is taped in place. An alternative
1. Stay very still. instruction is to ask the client to take a deep breath and
2. Exhale very quickly. hold the breath while the tube is removed.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver.
4. The nurse caring for a client with 2
a pneumothorax and who has had Rationale:
a chest tube inserted notes contin- Fluctuation with inspiration and expiration, not con-
uous gentle bubbling in the water tinuous bubbling, should be noted in the water seal
seal chamber. What action is most chamber. Intermittent bubbling may be noted if the
appropriate? client has a known pneumothorax, but this should de-
crease as time goes on and as the pneumothorax be-
gins to resolve. Therefore, the nurse should check for
1. Do nothing, because this is an
, Nclex questions 4100 exam 3
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expected finding. an air leak. If a wet chest drainage system is used, bub-
2. Check for an air leak, because bling would be continuous in the suction control cham-
the bubbling should be intermit- ber and not intermittent. In a dry system, there is no
tent. bubbling. Increasing the suction pressure only increas-
3. Increase the suction pressure so es the rate of evaporation of water in the drainage sys-
that the bubbling becomes vigor- tem; in addition, increasing the suction can be harmful
ous. and is not done without a specific prescription to do
4. Clamp the chest tube and notify so if using a wet system. Dry systems will allow for only
the health care provider immedi- a certain amount of suction to be applied; an orange
ately. bellow will appear in the suction window, indicating
that the proper amount of suction has been applied.
Chest tubes should be clamped only with a health care
provider's prescription.
5. The nurse is caring for a client 1, 3, 6
with lung cancer and bone metas- Rationale:
tasis. What signs and symptoms Oncological emergencies include sepsis, disseminated
would the nurse recognize as in- intravascular coagulation, syndrome of inappropriate
dications of a possible oncologicalantidiuretic hormone, spinal cord compression, hyper-
emergency? Select all that apply. calcemia, superior vena cava syndrome, and tumor lysis
syndrome. Blockage of blood flow to the venous system
of the head resulting in facial edema is a sign of supe-
1. Facial edema in the morning
rior vena cava syndrome. A serum calcium level of 12
2.Weight loss of 20 lb (9 kg) in 1
mg/dL (3.0 mmol/L) indicates hypercalcemia. Numb-
month
ness and tingling of the lower extremities could be a
3. Serum calcium level of 12 mg/dL
sign of spinal cord compression. Mild hypokalemia and
(3.0 mmol/L)
weight loss are not oncological emergencies. A sodium
4. Serum sodium level of 136
level of 136 mg/dL (136 mmol/L) is a normal level.
mg/dL (136 mmol/L)
5. Serum potassium level of 3.4
mg/dL (3.4 mmol/L)
, Nclex questions 4100 exam 3
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6. Numbness and tingling of the
lower extremities
6. The nurse is assessing the respi- 4
ratory status of a client who has Rationale:
suffered a fractured rib. The nurse Rib fractures result from a blunt injury or a fall. Typi-
should expect to note which find- cal signs and symptoms include pain and tenderness
ing? localized at the fracture site that is exacerbated by in-
spiration and palpation, shallow respirations, splinting
or guarding the chest protectively to minimize chest
1. Slow, deep respirations
movement, and possible bruising at the fracture site.
2. Rapid, deep respirations
Paradoxical respirations are seen with flail chest
3. Paradoxical respirations
4. Pain, especially with inspiration
7. A client with a chest injury has 3
suffered flail chest. The nurse as-
sesses the client for which most Flail chest results from multiple rib fractures. This re-
distinctive sign of flail chest? sults in a "floating" section of ribs. Because this section
is unattached to the rest of the bony rib cage, this
segment results in paradoxical chest movement. This
1. Cyanosis means that the force of inspiration pulls the fractured
2.Hypotension segment inward, while the rest of the chest expands.
3. Paradoxical chest movement Similarly, during exhalation, the segment balloons out-
4. Dyspnea, especially on exhala- ward while the rest of the chest moves inward. This is a
tion characteristic sign of flail chest.
8. The nurse is assessing a client 4
with multiple trauma who is at
risk for developing acute respira- The earliest detectable sign of acute respiratory distress
tory distress syndrome. The nurse syndrome is an increased respiratory rate, which can
should assess for which earliest begin from 1 to 96 hours after the initial insult to
sign of acute respiratory distress the body. This is followed by increasing dyspnea, air
