NCLEX
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
A) One cup of brown rice
B) One cup of lentils
C) One cup of pureed avocado
D) A dietary exception will need to be made: 4-6 ounces chicken daily
B) One cup of lentils
Answer Rationale:
The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?
A) The burned area is black in color and pain is absent
B) The burned area is pink in color with blisters present
C) The burned area is red in color with escar present
D) The burned area is yellow in color with severe edema
C) The burned area is red in color with eschar present.
Answer Rationale:
This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
A) Administer IV pain medication
B) Inspect the mouth for signs of inhalation injuries
C) Insert an indwelling urinary catheter
D) Draw blood for a complete blood cell (CBC) count
B) Inspect the mouth for signs of inhalation injuries.
Answer Rationale:
Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
A) Hypertention
B) Flusing of the skin
C) Bradypnea
D) Oliguria
D) Oliguria
Note: How do we quantify oliguria???
A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility?
A) Nurse Manager
B) The ordering physician
C) Hospital pharmacist
D) Medication sales representative
C) Hospital pharmacist
The nurse knows that a serum osmolality of 378 mOsm/kg indicates a patient who is
A) Overhydrated
B) Normal
C) Dehydrated
D) Hypokalemic
C. Dehydrated
A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function?
A) Apply downward pressure while the client shrugs his shoulders upward.
B) Apply resistance while the client lifts his legs from the bed.
C) Ask the client to grasp an object and form a fist.
D) Apply resistance while the client flexes his arms.
A) Apply downward pressure while the client shrugs his shoulders upward.
Answer Rationale:
This assessment monitors the motor function of C4 to C5
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
A) BP
B) Urine Output
C) HR
D) Weight
C) Heart Rate!!!
When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
*** Why is the answer NOT D?????
What are "priority shock related nursing diagnoses"
A) Altered urinary elimination
B) Fluid volume deficit
C) Anxiety
D) Decreased cardiac output
E) All of the above
B, C, D
A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?
A) Urine specific gravity 1.035
B) Hematocrit 44%
C) BUN 19 mg/dL
D) Sodium 155 mEq/L
A) Urine specific gravity 1.035
Answer Rationale:
A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030.
A patient with a stroke is being evaluated for fibrinolytic therapy. What information from the patient or family is most important for the nurse to obtain?
A. Loss of bladder control
B. Other medical conditions
C. Progression of symptoms
D. Time of symptom onset
D. Time of symptom onset
What is the classic triad associated with meningitis?
Nuchal rigidity, fever, and altered mental status
What is the most important nursing interventions for patients with meningitis....
monitoring and documenting of their neurologic status, including vital signs and neurovascular checks. Observe for early signs and symptoms of ICP.
What are signs and symptoms of increased cranial pressure?
How often will you assess neurological and vital signs after a craniotomy?
15-30 mins for the first 4-6 hours and then every hour
A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?
A. Patient with a Glasgow Coma Scale score that was 10 and is now 7
B. Patient with a Glasgow Coma Scale score that was 8 and is now 12
C. Patient with a moderate brain injury who is amnesic for the event
D. Patient who has a temperature of 102°F (38.9°C)
A. Patient with a Glasgow Coma Scale score that was 10 and is now 7
When assessing the pulmonary arterial waveform, the nurse notices dampening. After tightening the stopcocks and flushing the line, the nurse decides to calibrate the transducer. What are two essential components included in calibration?
A) Obtaining a baseline blood pressure and closing the transducer to air
B) Leveling the air–fluid interface to the phlebostatic axis and opening the transducer to air
C)Having the patient lay flat and closing the transducer to air
D)Obtaining blood return on line and closing all stopcocks
Ensuring accuracy of waveform calibration of the system includes opening the transducer to air and leveling the air–fluid interface of the transducer to the phlebostatic axis.
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?
A) Blood pressure 92/50 mm Hg
B) Heart rate 72/min
C) Abdominal pain rated 5 on a scale of 0 to 10
D) Respiratory rate 20/min
A) Blood pressure 92/50 mm Hg
Answer Rationale:
The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mm Hg. A blood pressure 92/50 mm Hg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.
The difference between primary and secondary multiple organ dysfunction syndrome (MODS) is that primary MODS is the result of
A) widespread systemic inflammation that results in dysfunction of organs not involved in the initial insult.
B) direct organ injury.
C) disorganization of the immune system response
D) widespread disruption of the coagulation systems
Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.
A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?
A) Place the client in protective isolation
B) Minimize environmental stimuli
C) Elevate the head of the client's bed 45 degrees
D) Limit the clients ambulation to once a day
B) Minimize environmental stimuli.
Answer Rationale:
A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.
The student learning about neurological disorders remembers that key features of increased intracranial pressure include which of the following? (Select all that apply.)
A. Projectile vomiting
B. Hyperactivity
C. Narrowed pulse pressure
D. Aphasia
E. Decerebrate posturing
A. Projectile vomiting
D. Aphasia
E. Decerebrate posturing
The value of SVO2 monitoring is to determine
A) Oxygen saturation at the capillary level.
B) an imbalance between oxygen supply and metabolic tissue demand.
C) the diffusion of gases at the alveolar capillary membrane.
D) the predicted cardiac output for acute pulmonary edema.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
A) Gradual onset of several hours
B) Manifestations preceded by a severe headache
C) Maintains consciousness
D) History of neurological deficits lasting less than 1 hour
B) Manifestations preceded by a severe headache
Answer Rationale:
A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.
A nurse is assessing a client who is receiving a continuous IV infusion of dopamine. Which of the following findings should the nurse recognize as a therapeutic effect?
A) Increased pulse
B) Increased urine output
C) Decreased blood pressure
D) Decreased dysrhythmia
B) Increased urine output
Answer Rationale:
Dopamine is used for the treatment of shock and heart failure. It increases cardiac output by increasing myocardial contractility. This medication also dilates renal blood vessels, which increases renal perfusion and leads to an increase in the client’s urinary output. This finding should indicate to the nurse a therapeutic effect has been achieved.
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
A) Administer a nitrate antihypertensive
B) Assess the client for bladder distention
C) Place the client in high-Fowler's position
D) Obtain the clients heart rate
C) Place the client in a high-Fowler’s position.
Answer Rationale:
The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse’s initial action should be to place the client in a high-Fowler’s position to assist in providing immediate reduction in blood pressure and intracranial pressure.