NCLEX Practice Quiz : Physiological Adaptation And Homeostasis

1. The RN has finished teaching a patient about treatment of GERD. The RN knows the patient has understood the teaching if she states:

“I should eat a small bedtime snack each night.”

“I should lie flat in bed.”

“I can have red wine with dinner.”

“I should eat six small meals daily.”

Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.

Explanation

Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.

2. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be:

Cover the areas with dry sterile dressings

Assess for dyspnea or stridor

Initiate intravenous therapy

Administer pain medication

Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.

Explanation

Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.

3. A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?

A prolonged inspiratory time and a short expiratory time.

Frequent productive coughing of clear, frothy, thin mucus progressing to thick, tenacious mucus heard only on auscultation.

Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations.

Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous.

Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.

Explanation

Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.

4. The nurse is caring for a 73-year-old patient with chronic pain being treated with opioids. One complication to be monitored for is:

Constipation

Diarrhea

Anorexia

Heartburn

Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.

Explanation

Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.

5. The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following?

Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken.

While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.

Explanation

While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.

6. An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his hematocrit is 30. The most likely cause of his anemia is:

Hemodilution secondary to fluid retention.

Eating insufficient protein due to taste changes that occur with dialysis.

Failure of his kidneys to produce the hormone necessary to stimulate bone marrow to produce red blood cells.

Hemolysis of red blood cells as they move past the membrane containing the dialysis solution.

Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.

Explanation

Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.

7. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?

Hemoglobin level of 12 g/dI

Pale mucosa of the eyelids and lips

Hypoactivity

A heart rate between 140 to 160

In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.

Explanation

In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.

8. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.

Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.

Explanation

Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.

9. An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what type of fracture this is. The nurse’s response is based on which of these understandings?

The ulnar bone has been crushed and broken in several places.

The two ends of the fractured ulnar bone are pulled apart and separated from each other.

The ulnar bone has been broken in two and one end of the bone broke through the skin.

Only one side of the ulnar bone is broken.

A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.

Explanation

A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.

10. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the
client’s pulse and respirations, what should be the function of the second nurse?

Relieve the nurse performing CPR

Go get the code cart

Participate with the compressions or breathing

Validate the client’s advanced directive

Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.

Explanation

Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.

11. The nurse is assisting a child with congestive heart failure. Which of the following would the child be least likely to manifest?

Weakness and fatigue.

Dyspnea

Tachycardia

Oliguria

Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.

Explanation

Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.

12. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?

What are you taking for pain and does it provide total relief?

What does the skin on the testicles look and feel like?

Do you have any questions about your care?

Did you know a consequence of epididymitis is infertility?

All of the questions should be asked. However, the one about the problem is the most important to start with at this time.

Explanation

All of the questions should be asked. However, the one about the problem is the most important to start with at this time.

13. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

S3 ventricular gallop

Apical click

Systolic murmur

Split S2

S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.

Explanation

S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.

14. A child who is two years and six months old has had one bout of nephrosis (nephrotic syndrome). His mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm this condition by recognizing what additional symptom?

Blood pressure of 140/90.

Marked proteinuria

Cola-colored urine

A history of positive streptococcal infection

Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.

Explanation

Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.

15. One of the most important pulmonary treatments in cystic fibrosis is:

Inhaled beta agonists.

Inhaled corticosteroids

Chest physiotherapy

Oral enzymes

The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Inhaled beta agonists and inhaled corticosteroids are used but are secondary to chest physiotherapy; the oral enzymes that CF patients take are for digestion, not pulmonary reasons

Explanation

The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Inhaled beta agonists and inhaled corticosteroids are used but are secondary to chest physiotherapy; the oral enzymes that CF patients take are for digestion, not pulmonary reasons

16. The nurse is assessing a client admitted in ketoacidosis. The nurse can expect the client’s skin to be:

Clammy

Flushed

Diaphoretic

Silky

Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.

Explanation

Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.

17. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?

Lower extremity pitting edema

Rales

Jugular vein distension

Weakness in left arm

In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.

Explanation

In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.

18. A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations 24; B.P. 110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the cause of these findings?

Damage to the hypothalamus resulting in decreased hormone production.

Movement of fluid from the tissue into the intravascular space, resulting from sepsis.

An increase in antidiuretic hormone (ADH) as a result of injury to the hypothalamus.

Fluid shifts from the tissue into the intravascular space due to administration of normal saline used during fluid resuscitation.

Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.

Explanation

Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.

19. The RN is caring for a patient with a chest tube after a right upper lobectomy. On the day of surgery, the RN notes bubbling in the water-seal chamber. What is this, and what should the RN do?

Air leak, expected finding

Air leak, notify physician

Suction control, expected finding

Suction control, decrease wall suction

Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; notifying physician would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.

Explanation

Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; notifying physician would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.

20. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?

Active and passive range of motion exercises twice a day

Every 4 hours incentive spirometer

Chest physiotherapy twice a day

Repositioning every 2 hours around the clock

These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, Active and passive range of motion exercises twice a day and every 4 hours incentive spirometer are inadequate with this problem in mind. Repositioning every 2 hours around the clock is not specific for prevention of complications associated with the lung.

Explanation

These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, Active and passive range of motion exercises twice a day and every 4 hours incentive spirometer are inadequate with this problem in mind. Repositioning every 2 hours around the clock is not specific for prevention of complications associated with the lung.