Fundamentals Of Nursing NCLEX Quiz 18

2.

Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?

Minimizes muscle spasms
Prevents hemorrhage
Increases circulation
Reduces discomfort

Correct Answer

A. Increases circulation

Explanation

Heat increases the skin surface temperature. promoting vasodilation. which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction. which decreases blood flow to the area. Both heat and cold relax muscles and thus minimize muscle spasms. There is no advantage to using heat over cold. (option 1). Heat does not prevent hemorrhage; heat causes vasodilation. which promotes hemorrhage (option 2). Both heat and cold can reduce discomfort. Cold reduces discomfort by numbing the area. slowing the transmission of pain impulses. and increasing the pain threshold. Heat reduces the discomfort by relaxing the muscles (option 4).

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3.

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?

Increase blood pressure.
Weak. rapid pulse.
Moist mucous membranes.
Jugular vein distention.

Correct Answer

A. Weak. rapid pulse.

Explanation

All other options are indicated of fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing fluid volume deficit.

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2

4.

Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that the teaching is affected when the patient says its purpose is to:

Precipitate coughing.
Help maintain open airways.
Decrease intrathoracic pressure.
Facilitate expectoration of mucus

Correct Answer

A. Help maintain open airways.

Explanation

Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs. which prolongs exhalation and maintains positive airway pressure. thereby maintaining an open airway and preventing airway collapse. Deep breathing and huff coughing. not pursed lip breathing. stimulate effective coughing (option 1). Pursed lip breathing increases. not decreases intrathoracic pressure (option 3). The huff coughing stimulates the natural cough reflex and is effective for clearing the central air ways of sputum. Saying the word huff with short forceful exhalations keeps the glottis open. mobilizes sputum. and stimulates a cough (option 4).

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5.

A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioners order?

Emphysema.
Osteoporosis.
Cystic fibrosis.
Chronic bronchitis

Correct Answer

A. Osteoporosis.

Explanation

Implementing the practitioners order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. Option 1: These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. Option 3: These are appropriate interventions for a patient with cystic fibrosis cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick. tenacious secretions in the respiratory system that block the bronchioles. creating breathing difficulties. Option 4: These are appropriate interventions for a patient with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.

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6.

What should Nurse Mavie do first if a patient is choking on food?

Apply sharp for thrusts over the patient’s xiphoid process.
Determine if the patient can make any verbal sounds.
Hit the middle of the patients back firmly.
Sweep the patient’s mouth with a finger

Correct Answer

A. Determine if the patient can make any verbal sounds.

Explanation

When a person is choking on food. the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction. the person will be able to make sounds because some air can pass from the lungs through the vocal chords. In this situation the person’s own efforts open parentheses gagging and coughing) should be allowed to clear the airway. With a total airway obstruction. the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver). Thrusts to the xiphoid process may cause a fracture that may result in a pneumothorax (option 1).

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1

7.

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?

Start an IV.
Review the results of serum electrolytes.
Offer the woman foods that are high in sodium and potassium content.
Administer an anti-a medic

Correct Answer

A. Review the results of serum electrolytes.

Explanation

Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options one. three. and four. assessment is needed initially.

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2

8.

Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply.

Restlessness.
Tachypnea.
Bradycardia.
Confusion.
Pallor.

Correct Answer(s)

A. Restlessness.
A. Tachypnea.
A. Pallor.

Explanation

Restlessness. tachypnea. and pallor are early manifestations of hypoxemia. along with tachycardia. elevated blood pressure. use of accessory muscles. nasal flaring. tracheal tugging. and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia. along with stupor. cyanotic skin and mucous membranes. bradypnea. hypotension. and cardiac dysrhythmias.

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1

9.

A nurses caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply.

Apply the oxygen source loosely if the SPO2 increases during the procedure.
Use surgical asepsis to remove and clean the inner cannula.
Clean the outer surfaces in a circular motion from the stoma site outward.
Replace the tracheostomy ties with new ties.
Cut a slit in gauze squares to place beneath the tube holder.

Correct Answer(s)

A. Apply the oxygen source loosely if the SPO2 increases during the procedure.
A. Use surgical asepsis to remove and clean the inner cannula.
A. Clean the outer surfaces in a circular motion from the stoma site outward.

Explanation

The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. Option 3 helps move mucus and contaminated material away from the stoma for easy removal. Option 4: To help keep the skin clean and dry. the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgment with replacing the ties. so he should not replace them routinely. Option 5: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate.

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10.

Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply.

Apply suction while withdrawing the catheter.
Perform suctioning on a routine basis. every 2 to 3 hours.
Maintain medical asepsis during suctioning.
Use a new catheter for each suctioning attempt.
Limit suctioning to 2 to 3 attempts.

Correct Answer(s)

A. Apply suction while withdrawing the catheter.
A. Use a new catheter for each suctioning attempt.
A. Limit suctioning to 2 to 3 attempts.

Explanation

The nurse should apply suction pressure only while withdrawing the catheter. not while inserting it. The nurse should not reuse the suction catheter unless an in-line suctioning system is in place. To prevent hypoxemia. the nurse should limit each section in session to 2 to 3 attempts and allow at least one minute between passes for ventilation and oxygenation. The nurse should not suction routinely because suctioning is not without risk. It can cause mucosal damage. bleeding. and bronchospasm. Endotracheal suctioning requires surgical asepsis.

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Fundamentals Of Nursing NCLEX Quiz 18

Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority?

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Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?

Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that the teaching is affected when the patient says its purpose is to:

A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioners order?

What should Nurse Mavie do first if a patient is choking on food?

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?

Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply.

A nurses caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply.

Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply.