NCLEX Practice Exam 43 (10 Questions)

1. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority?

Irrigate the eye repeatedly with normal saline solution.

Place fluorescein drops in the eye.

Patch the eye.

Test visual acuity.

Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash. nor is patching the eye. Following irrigation. visual acuity will be assessed.

Explanation

Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash. nor is patching the eye. Following irrigation. visual acuity will be assessed.

2. A patient with a history of diabetes mellitus is in the second post-operative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?

Anesthesia reaction.

Hyperglycemia.

Hypoglycemia.

Diabetic ketoacidosis.

A postoperative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.

Explanation

A postoperative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. An anesthesia reaction would not occur on the second post-operative day. Hyperglycemia and ketoacidosis do not cause confusion and shakiness.

3. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings?

Complaints of pain during repositioning.

Scant bloody discharge on the surgical dressing.

Complaints of pain following physical therapy.

Temperature of 101.8 F (38.7 C).

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

Explanation

Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing.

4. A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient's lab results would expect which of the following changes in laboratory findings?

Elevated serum calcium.

Low serum parathyroid hormone (PTH).

Elevated serum vitamin D.

Low urine calcium.

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism. the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated. with calcium spilling over from elevated serum levels. This may cause renal stones.

Explanation

The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism. the serum calcium level will be elevated. Parathyroid hormone levels may be high or normal but not low. The body will lower the level of vitamin D in an attempt to lower calcium. Urine calcium may be elevated. with calcium spilling over from elevated serum levels. This may cause renal stones.

5. A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain. fever. and chills. Which of the following conditions poses the most immediate concern?

Bowel perforation.

Viral gastroenteritis.

Colon cancer.

Diverticulitis.

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain. fever. chills. and tachycardia. which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not cause these symptoms. Diverticulitis may cause pain. fever. and chills. but is far less serious than perforation and peritonitis.

Explanation

Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain. fever. chills. and tachycardia. which indicate advancing peritonitis. Viral gastroenteritis and colon cancer do not cause these symptoms. Diverticulitis may cause pain. fever. and chills. but is far less serious than perforation and peritonitis.

6. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included?

Notify the physician.

Restrain the patient’s limbs.

Position the patient on his/her side with the head flexed forward.

Administer rectal diazepam.

During a witnessed seizure. nursing actions should focus on securing the patient’s safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back. blocking the airway. Rectal diazepam may be a treatment ordered by the physician. who should be notified of the seizure.

Explanation

During a witnessed seizure. nursing actions should focus on securing the patient’s safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back. blocking the airway. Rectal diazepam may be a treatment ordered by the physician. who should be notified of the seizure.

7. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads?

The left clavicle and right lower sternum.

Right of midline below the bottom rib and the left shoulder.

The upper and lower halves of the sternum.

The right side of the sternum just below the clavicle and left of the precordium.

One gel pad should be placed to the right of the sternum. just below the clavicle and the other just left of the precordium. as indicated by the anatomic location of the heart. To defibrillate. the paddles are placed over the pads. Options A. B. and C are not consistent with the position of the heart and are therefore incorrect responses.

Explanation

One gel pad should be placed to the right of the sternum. just below the clavicle and the other just left of the precordium. as indicated by the anatomic location of the heart. To defibrillate. the paddles are placed over the pads. Options A. B. and C are not consistent with the position of the heart and are therefore incorrect responses.

8. A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is NOT recommended?

A diet high in grains.

A diet with adequate caloric intake.

A high protein diet.

A restricted sodium diet.

A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates. including grains.

Explanation

A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Adequate caloric intake is recommended with a diet high in protein and complex carbohydrates. including grains.

9. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct?

The frequency and intensity of bowel sounds varies depending on the phase of digestion.

In the presence of intestinal obstruction. bowel sounds will be louder and higher pitched.

A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.

All of the above.

All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds. which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism. for example. and should always be considered abnormal.

Explanation

All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds. which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism. for example. and should always be considered abnormal.

10. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply.

Partial thromboplastin time.

Prothrombin time.

Platelet count.

Hemoglobin

Prothrombin time. partial thromboplastin time. and platelet count are all included in coagulation studies. The hemoglobin level. though important information prior to an invasive procedure like liver biopsy. does not assess coagulation.

Explanation

Prothrombin time. partial thromboplastin time. and platelet count are all included in coagulation studies. The hemoglobin level. though important information prior to an invasive procedure like liver biopsy. does not assess coagulation.

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