NCLEX Test Taking Strategy Questions, Exams of Nursing

Download NCLEX Test Taking Strategy Questions and more Exams Nursing in PDF only on Docsity! Day 4 1 NCLEX Test Taking Strategy Questions2023 1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the client’s urine output suddenly increases significantly. Which action takes highest priority? o 1. Monitoring urine output o 2. Checking pulse o 3. Checking blood pressure o 4. Assessing level of consciousness Rationale: 3. Correct: This is the best answer because we are “worried” this client is going into SHOCK. So…..you better be checking a BP. This is a time where checking the BP is appropriate. If we “assume the worst” I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP. 4. Incorrect: If my client is going into shock the highest priority is to assess the BP. 2. The client is being treated for fluid volume deficit. Which is an expected outcome of successful treatment? o 1. Resolution of orthostatic hypotension o 2. Maintenance of weight loss o 3. Compliance with sodium restricted diet o 4. Maintenance of serum Na above 148 mEq Rationale: 1. Correct: When you are in a fluid volume deficit your blood pressure goes down when you stand up and it’s called orthostatic hypotension. Successful treatment would resolve this. 2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my weight should go up. 3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume excess. 4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as dehydration, so this means that you are still sick. Page 2 of 68 Day 4 5 5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal failure. What is the initial client response to this problem? o 1. Respiratory rate increases to blow off acid. o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response. o 3. Kidneys will excrete hydrogen and retain bicarb. o 4. Sodium will shift to cells and buffer the hydrogens. Rationale: 1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe faster to blow off some acid. The respiratory response is fast. 2. Incorrect: No, the client’s respiratory rate is fast, not slow. 3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response. 4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte. 6. The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance is suspected? o 1. Hypercalcemia o 2. Hypokalemia o 3. Hypermagnesemia o 4. Hyponatremia Rationale: 2. Correct: The client has been vomiting so the electrolytes losses are potassium, hydrogen and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is potassium. 1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing 3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related to dysrhythmias. 4. Incorrect: The loss of sodium is related to diarrhea. Page 6 of 68 Day 4 7 7. The nurse is caring for a client that is drowsy and has an elevated CO2. What are some common drugs that cause retained CO2? Select all that apply  1. Narcotics  2. Diuretics  3. Steroids  4. Antiemetics  5. Hypnotics Rationale: 1., 4. & 5. Correct: Yes! – Narcotics sedate and decrease the respiratory rate. Some antiemetics like promethazine (Phenergan) are very sedating. Hypnotics can cause sedation to point of hypoventilation. 2. Incorrect: No – Diuretics do not affect breathing patterns. 3. Incorrect: No –Steroids do not affect breathing patterns 8. A client was admitted 24 hours ago with sepsis. Treatment included IV therapy of lactated Ringers (LR) at 150 ml/hr, broad spectrum antibiotics, and steroid therapy. How will the nurse know that treatment has been successful? Select all that apply.  1. Blood pressure 96/68; HR- 98; RR- 20  2. Serum Glucose- 110  3. Hgb- 12; Hct- 38  4. pH- 7.30; pCO2- 48; HCO3- 24 3. Incorrect: Not metabolic condition, because HCO3 is normal. 4. Incorrect: Not metabolic condition, because HCO3 is normal. Page 10 of 68 Day 4 11 10. The nurse is caring for a client, who is 8 hours post- op receiving 40% humidified oxygen. ABG results are: pO2= 91, pCO2= 50, pH= 7.30, HCO3= 24. Based on this information, which nursing action would be best? o 1. Turn client and encourage coughing and deep breathing. o 2. Request respiratory therapy to perform postural drainage and percussion. o 3. Report ABGs to physician and increase oxygen percentage. o 4. Administer anti-anxiety agent. Rationale: 1. Correct: If you had just a colectomy would you be taking nice deep breaths? No. So what would you be retaining? CO2 which makes your pCO2 go up, which makes your pH go down. I’m acidotic aren’t I? 2. Incorrect: Requesting postural drainage and percussion form respiratory therapy would not be the best nursing action to address the problem of retaining CO2. 3. Incorrect: There’s nothing wrong with calling the physician and letting him know about the ABGs but the last part is just wrong. How is oxygen going to help this client? It’s not until they get rid of the what? CO2. And the only way to rid of the CO2 is coughing and deep breathing. 4. Incorrect: What are they going to say about you if you select #4? You’re a killer. Don’t give her a license, because if you give them an anti-anxiety agent what’s going to happen to the respiratory rate, decrease, and they are going to retain even more CO2 and you’ve just made it worse. 11. After completing a round of chemotherapy, the client’s lab results revealed. Based on this data, what problem should the nurse anticipate? Select all that apply.  1. Anemia  2. Leukopenia  3. Thrombocytopenia  4. Hypernatremia  5. Hypokalemia Rationale: 1., 2. & 3. Correct: Chemotherapy decreases bone marrow production, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). 4. Incorrect: The sodium level is normal. Page 12 of 68 Lab Results Hgb- 9.0g/dl Hct- 28% WBC- 3,000 mm3 Platelets- 94,000 mm3 Na- 142mEq/L K- 3.8 mEq/L Day 4 15 2. Correct: The current of electrical burns damages the vascular system and the nerves nearby. This alteration in the vascular system can damage vital organs, and we worry about organ failure. 1. Incorrect: Bones are dense and not really affected by electrical current. 3. Incorrect: Cardiac monitoring is for the first 48 hours, not the reason for a prolonged stay. 4. Incorrect: Infection is not a priority in an electrical burn. 14. A client is hospitalized hundreds of miles from home for a bone marrow transplant. The client is in reverse isolation while undergoing total body irradiation and intense chemotherapy. The client’s sibling, who has driven a great distance, comes to visit and has obvious manifestations of an upper respiratory infection. Which nursing action would be most appropriate at this time? o 1. Do not allow the sibling to visit, and do not upset the client by mentioning the sibling’s visit. o 2. Allow the sibling to wave at the client through the window or door, then offer the use of the unit phone so they can talk. o 3. Allow the sibling to visit donning a sterile gown, mask, and gloves, but prohibit physical contact. o 4. Allow the sibling to visit after donning a sterile gown, mask, and gloves and have the client wear a mask. Rationale: 2. Correct: This is the only safe answer for the client. 1. Incorrect: No, allow client to see from distance and talk with client. 3. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing. 4. Incorrect: Sibling does not need to be allowed in the room regardless of protective clothing. 15. A client is admitted to the Emergency Department with burns to the chest and legs. Which assessment is the highest priority? o 1. Calculating the “Rule of Nines” o 2. Determining the time of the burn Page 16 of 68 Day 4 17 o 3. Ascertaining if the burn occurred in an enclosed area o 4. Calculating the Parkland formula Rationale: 3. Correct: A fire in an enclosed area brings on the concern for carbon monoxide poisoning. In addition with the burns to the chest there is the added potential for airway damage. 1. Incorrect: Important for surface area estimate but not airway. 2. Incorrect: Important for fluid replacement but not #1. 4. Incorrect: Determines the amount of fluid to be replaced, but not airway! 18. The nurse is evaluating whether a client understands the procedure for collecting a 24 hour urine sample. The nurse recognizes that teaching was successful when the client makes which statements? Select all that apply.  1. “I should start the 24 hour urine collection at the time of my first saved urine specimen.”  2. “If I forget to collect any urine, I will need to start over.”  3. “It is important to ensure that no feces or toilet tissue mixes with the urine.”  4. “When the 24 hours is up, I need to void and collect that specimen.”  5. “The urine specimen should be stored in my refrigerator during collection.” Rationale: 2., 3. & 4. Correct: Missed specimens make the collection inaccurate. The test should be started over. Contamination can alter the test. The last specimen should be obtained at the end of the 24 hour period. 1. Incorrect: The time begins with the first voiding, however that voiding is discarded. 5. Incorrect: Urine should be placed on ice or left at room temperature if an additive has been used. You do not want the client to store the specimen in their refrigerator. 19. After gathering supplies, explaining the procedure, putting the client in a high fowlers position, and washing hands, the nurse begins to clean a client’s tracheostomy. Place the steps in the proper order. All options must be used. Page 20 of 68 1. Soak inner cannula in peroxide. 2. Reinsert cannula with non-dominant hand and lock into place. 3. Prepare sterile supplies, hydrogen peroxide and normal saline. 4. Don sterile gloves. 5. Rinse and dry inner cannula with pipe cleaner. 6. Put on clean gloves to remove soiled dressing. Day 4 21 Rationale: 6., 3., 4., 8., 1., 5., 2., 7. & 9. Correct: This is the proper procedure for trach care. 20. The client with Addison’s disease demonstrates an understanding of steroid therapy by which statement? o 1. “I’ll take my medicine at night to help me sleep.” o 2. “My medication dosage will be adjusted frequently.” o 3. “I will limit my sodium intake to 200 mg per day.” o 4. “I will weigh myself weekly to monitor medication effectiveness.” Rationale: 2. Correct: Steroid therapy is adjusted according to the client’s weight and signs of fluid volume status. 1. Incorrect: Steroids can cause insomnia. 3. Incorrect: This client needs a high sodium diet as they are losing sodium and retaining potassium. 4. Incorrect: Weights are done daily to adjust medication dosage not weekly. 21. The nurse is admitting a client with new onset Diabetes mellitus. Which findings does the nurse expect while completing the medical history and physical examination of this client? Select all that apply.  1. History of recurrent vaginal yeast infections  2. Complaints of intolerance to the cold  3. Slow, slurred speech noted  4. Prescription change for glasses needed twice in past year  5. Complaints of wanting to eat all the time  6. Page 22 of 68 Day 4 25 o 1. Have the client sit with you and say a prayer. o 2. Explain that shouting is not allowed and send them to group session. o 3. Redirect the client to another activity. o 4. Call for assistance and put the client in seclusion. Rationale: 3. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now. 1. Incorrect: They are agitated, shouting…Now you think it is reasonable to get them to sit and pray? Nope! 2. Incorrect: Setting limits is good, but here the client is disruptive. 4. Incorrect: Oh boy – it’s going to be a fight! NO! That’s not nice. 24. Which dietary consideration is the most important for the nurse to teach to a client with hypothyroidism? o 1. Increase carbohydrate intake. o 2. Increase fluid intake. o 3. Avoid shellfish. o 4. Increase fiber. Rationale: 4. Correct: YES! Low thyroid clients have constipation, so increased fiber. 1. Incorrect: No they need less calories, not more. Their metabolism is slowed. 2. Incorrect: What does increasing fluid have to do with it? Nothing 3. Incorrect: What does avoiding shellfish have to do with it? Nothing…that’s if they are allergic to iodine. 25. Following a thyroidectomy a client is complaining of shortness of breath and neck pressure. What should the nurse do? o 1. Stay with the client, remove the dressing, and elevate the head of bed. o 2. Call a code, open the trach set and position the client flat supine. o 3. Have the client say “EEE” to check for laryngeal integrity and assess Chvostek’s sign. o 4. Call the doctor and assess vital signs. Page 26 of 68 Day 4 27 Rationale: 1. Correct: Yes! Sounds like respiratory distress, Looks like respiratory distress, get that dressing off the neck and see if they can breathe any better. 2. Incorrect: Not yet! Do something first to see if it gets better. 3. Incorrect: Well just look and check and look and check – do something. 4. Incorrect: Don’t leave the client. 28. A six-year-old client has been receiving chemotherapy for two weeks. The laboratory results show a platelet count of 20,000. What is the priority nursing action? o 1. Encourage quiet play. o 2. Avoid persons with infections. o 3. Administer p.r.n. oxygen. o 4. Provide foods high in iron. Rationale: 1. Correct: With a low platelet count you are at risk for bleeding, and quiet play will decrease the risk of injury. 2. Incorrect: The priority is risk for bleeding with the low platelet count, not infection. 3. Incorrect: There is no indication that client has low RBC’s or anemia. 4. Incorrect: There is no indication that client has low iron. 29. A nurse is caring for a client diagnosed with heart failure (HF). The client currently takes furosemide (Lasix) 40mg every morning. Potassium 20mEq daily, digoxin (Lanoxin) 0.25mg every day. Which client comment should the nurse assess first in caring for this client? o 1. “My fingers and feet are swollen.” o 2. “My weight is up 1 pound.” o 3. “There is blood in my urine.” o 4. “I am having trouble with my vision.” Page 30 of 68 Day 4 31 Rationale: 4. Correct: Did you see the sign of Dig toxicity? Good Job! 1. Incorrect: History of heart failure, edema is common- may need bed rest or additional diuretic therapy- not usually life threatening. 2. Incorrect: No, weight should not vary more than 3-5 pounds. 3. Incorrect: Needs investigation, but digoxin toxicity comes first- more lethal. 30. After a left heart catheterization, a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and cold extremity. What should be the nurse’s next action? o 1. Administer an anticoagulant . o 2. Warm the room and re-assess. o 3. Increase IV fluids. o 4. Notify the physician stat. Rationale: 4. Correct: This is an emergency, and the doctor is the only one that can save this foot from ischemia – don’t delay. 1. Incorrect: Anticoagulants stabilize clots, not lyse – thrombolytics lyse clots..too aggressive – just report and get some help coming. 2. Incorrect: These symptoms are too severe for warming the room. 3. Incorrect: Well, in theory, increasing blood volume increases blood flow – but this client has an arterial obstruction. 31. A client is admitted to the medical unit with a diagnosis of Addison’s disease. What nursing interventions should the nurse implement for this client? Select all that apply.  1. Administer potassium supplements as ordered.  2. Assist the client to select food high in sodium.  3. Administer Fludrocortisone (Florinef) as ordered.  4. Monitor intake and output. Page 32 of 68 Day 4 35 counting aloud to get rid of some energy. Rationale: 1. Correct: Yes! Get them away and doing something purposeful. 2. Incorrect: That is embarrassing and humiliating to the client. 3. Incorrect: Sometimes this will be helpful during times of therapy – but the client is manic at this time, will she even believe them? 4. Incorrect: No, this is getting her active, but can the group continue with this attention seeking jumping, counting person? No. Get her away from the activity. 34. After examining the eyes of the following client, the nurse would expect which correlating lab work? o 1. Elevated cortisol level o 2. Elevated thyroxine levels o 3. Decreased parathormone levels o 4. Increased calcitonin level Rationale: 2. Correct: Exophthalmos is a classic finding in Graves’ disease. It is a protrusion of the eyeballs from the orbits due to impaired venous drainage from the orbit, which causes increased fat deposits and edema in the retro-orbital tissues. To diagnose hyperthyroid or Grave’s Disease you do a thyroxine level which when elevated indicates a hyperthyroid state. 1. Incorrect: This would indicate hyperfunctioning of the adrenal gland as in Cushing ’s syndrome. 3. Incorrect: This lab would indicate hypoparathyroidism. 4. Incorrect: Again, this level would tell you about the parathyroid. 35. A client with schizophrenic disorder begins to talk about fantasy material. What would be the most appropriate nursing action? Page 36 of 68 Day 4 37 o 1. Encourage the client to focus on reality-based issues. o 2. Allow the client to continue to talk so as not to interrupt the delusion. o 3. Ask the client to explain the meaning behind what he is saying. o 4. Persuade the client that his thoughts are not true. Rationale: 1. Correct: Get them out of the delusion to get into the real world. 2. Incorrect: Never allow clients to continue on in a delusion….this is reinforcing it. 3. Incorrect: Reinforcing the delusion. 4. Incorrect: Waste of time….produces anxiety. 38. A client with a T4 lesion is being cared for on the neuro rehabilitation unit. The client suddenly complains of a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate? Select all that apply.  1. Place the client supine with legs elevated.  2. Assess bladder and bowel for distention.  3. Examine skin for pressure areas.  4. Eliminate drafts.  5. Remove triggering stimulus.  6. Administer hydralazine (Apresoline) if BP does not return to normal. Rationale: 2., 3., 4., 5. & 6. Correct: All appropriate interventions for autonomic dysreflexia. This condition occurs in clients with a T6 or lower injury. The autonomic nervous system sends out a massive sympathetic response (epi and norepi) to stimuli. The stimuli is one that would not bother a healthy person but very dangerous to a spinal injury client, i.e. bladder or bowel distention, pressure areas in the bed, drafts, and other simple triggers. 1. Incorrect: The client should be placed immediately in a sitting position to lower blood pressure. 39. A client who is fourth day post-op cholecystectomy complains of severe abdominal pain. During the initial assessment he states, “I have had two almost black stools today.” Which nursing action is most important? o 1. Start an IV with D5W at 125 ml/hr. Page 40 of 68 Day 4 41 o 2. Insert a nasogastric tube. o 3. Notify the physician. o 4. Obtain a stool specimen. Rationale: 3. Correct: What’s going on inside? They are hemorrhaging. Assume the worst. The physician is the only one who can stop the bleeding. 1. Incorrect: There’s nothing wrong with starting an IV, but isn’t the client bleeding while you do this? 2. Incorrect: How does that help the bleeding stop? It doesn’t. 4. Incorrect: You are going to wait on a stool specimen and Hemoccult. Don’t delay care, notify the physician first. 40. A construction worker comes into the occupational health nurse’s clinic complaining of chest heaviness. What other signs and symptoms does the nurse expect to find if myocardial infarction is suspected? Select all that apply.  1. Headache  2. Indigestion  3. Lightheadedness  4. Dyspnea  5. Irregular pulse Rationale: 2., 3., 4. & 5. Correct: Chest pains or discomfort not relieved by rest or nitroglycerin. Palpitation. If heart failure occurs, BP maybe increases because of sympathetic stimulation or decreased because of decreased contractility, impending cardiogenic shock, medications. Irregular pulse due to artial fibrillation, shortness of breath, tachypnea, crackles due to pulmonary congestion, n/v, decreased UOP due to cardiogenic shock, as well as cool clammy skin. Anxiety, restlessness, lightheadedness. 1. Incorrect: Headaches do not commonly occur with MI. 41. The nurse is caring for a client complaining of intense headaches with increasing pain for the past month. A Magnetic Resonance Imaging (MRI) is ordered. In reviewing the client’s information, which piece of information is of concern? o 1. Allergic to shellfish o 2. Cardiac pacemaker Page 42 of 68 Day 4 45 o 1. Encourage client to cook for others. o 2. Weight the client daily and keep a journal. o 3. Restrict access to mirrors. o 4. Monitor food intake and behavior for one hour after meals. Rationale: 4. Correct: Yes! This is the primary problem and the most life threatening. 1. Incorrect: No – remember the focus is on control and attention to food – they need to eat. 2. Incorrect: No – we don’t let them know their weight, if they gain one ounce, they will try anything to lose it! 3. Incorrect: They still have to brush their hair and put on make-up – it’s the eating we just focus on to keep them alive. 44. Which condition would warrant the nurse discontinuing the intravenous infusion of oxytocin (Pitocin)? o 1. Fetal heart rate baseline of 140-160 bpm o 2. Contractions every 1-1/2 minutes lasting 70-80 seconds o 3. Maternal temperature of 101.2 degrees o 4. Early decelerations in the fetal heart rate Rationale: 2. Correct: These contractions are too long and too often. 1. Incorrect: That heart rate is fine. 3. Incorrect: Temperature has nothing to do with Pitocin (uterine contractions). 4. Incorrect: Early decels are no big deal. 45. In preparing care for a client with Parkinson’s disease, which nursing diagnoses should the nurse include? Select all that apply.  1. Impaired physical mobility related to muscle rigidity  2. Imbalanced nutrition, greater than body requirements related to limited exercise  3. Self-care deficits related to motor disturbance  4. Impaired verbal communication related to inability to move facial muscles  5. Unilateral neglect related to muscle paralysis. Rationale: Page 46 of 68 Day 4 47 1., 3. & 4. Correct: These are appropriate nursing diagnoses for a client with Parkinson’s disease. 2. Incorrect: The client is more likely to have imbalanced nutrition, less than body requirements, related to tremor, slowness in eating, difficulty in chewing and swallowing. 48. The nurse is caring for a client with pneumonia. Which nursing observation would indicate a therapeutic response to the treatment for the infection? o 1. Oral temperature of 101 degrees F., increased chest pain with non-productive cough o 2. Productive cough with thick green sputum, states feels tired o 3. Respirations 20, with no complaints of dyspnea, moderate amount of thick white sputum o 4. White cell count of 10,000 mm3, urine output at 40 cc/hr, no sputum Rationale: 3. Correct: You will have sputum a while after pneumonia, but if it is white there is no infection. 1. Incorrect: Temperature is still too high and they are having chest pains. 2. Incorrect: Green sputum means infection is still there. 4. Incorrect: If pneumonia is the problem, you do not check kidneys. With pneumonia you will have sputum for a while. 49. Which nursing action would be included in planning care for a client with signs of increased intracranial pressure? o 1. Encourage coughing and deep-breathing to prevent pneumonia. o 2. Suction airway every 2 hours to remove secretions. o 3. Position the client in the prone position to promote venous Page 50 of 68 Day 4 51 return. o 4. Determine cough reflex and ability to swallow prior to administering PO fluids. Rationale: 4. Correct: If I have increased ICP my reflexes could be suppressed. 1. Incorrect: Makes ICP go up. 2. Incorrect: Makes ICP go up. 3. Incorrect: Makes ICP go up. 50. Which postpartum client requires the last private room in the Women’s Health Center? o 1. A client who had an abruption during her delivery 22 hours ago o 2. A client who had a boggy fundus five hours post-delivery o 3. A client who was pre-eclamptic prior to delivery 30 hours ago, with vital signs now normal. o 4. A client who delivered by c-section whose WBC count is 24,000 Rationale: 3. Correct: This pre-eclamptic client delivered 30 hours ago….They are trying to make you think that everything is OKAY because they say AFTER delivery… they must have a private room because ANY STIMULI can precipitate a seizure. 1. Incorrect: People who are at risk for bleeding and shock do not require private rooms. 2. Incorrect: Boggy fundus….doesn’t have anything to do with a private room. 4. Incorrect: This is the one most people jump on…. They thought you would jump on this…all ladies who have had babies have elevated white counts post-delivery. 51. The nurse will be admitting a client from the operating room following a left pneumonectomy for adenocarcinoma. Which type of chest drainage system should the nurse anticipate the client will have? Page 52 of 68 Day 4 55 Rationale: 3. Correct: Hallmark of flail chest! 1. Incorrect: No, but it’s associated with neurological problems. 2. Incorrect: Open chest wounds suck not closed chest wounds. 4. Incorrect: Well, the hypoxia and trauma will lead to hypotension and tachycardia, not bradycardia. 54. The nurse is caring for a client 28 weeks pregnant that complains of swollen hands and feet. Which symptom below would cause the most concern? o 1. Nasal congestion o 2. Hiccoughs o 3. Capillary blood glucose of 150 o 4. Muscle spasms Rationale: 4. The muscle spasms – watch for seizure. 1. No, they always have a stuffy nose. 2. Hiccoughs would be second best answer indicating nerve/muscle irritation. 3. Is this right after dairy queen? 55. The nurse is writing a care plan for a client admitted following chest tube placement for a spontaneous pneumothorax. Which intervention would be appropriate for the nurse to include? o 1. Keep the water seal chamber at the level of the right atrium. o 2. Tape all connections between the chest tube and drainage system. o 3. Notify the physician if there is continuous bubbling in the suction control chamber. o 4. Empty the collection chamber and record the amount of drainage every shift. Page 56 of 68 Day 4 57 Rationale: 2. Correct: Tape all connections. 1. Incorrect: Must be kept below the chest. 3. Incorrect: If it’s hooked to suction it’s suppose to bubble. 4. Incorrect: Empty every shift? Don’t empty them, you change them out when they get full. 58. The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bed rest. What is the most important assessment at this time? o 1. Protein in the urine o 2. Fetal heart tones o 3. Cervical dilation o 4. Hemoglobin and hematocrit levels Rationale: 4. Correct: The client may be bleeding! And that is an emergency! 1. Incorrect: We are not worried about pre-ecclampsia right now with this situation . 2. Incorrect: We can’t hear them yet. 3. Incorrect: No vaginal exams! We don’t want any stimulation to the cervix now. 59. A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation? Select all that apply.  1. “I should not cross my affected leg over my other leg.”  2. “I should not bend at the waist more than 90 degrees.”  3. “While lying in bed, I should not turn my affected leg inward.” Page 60 of 68 Day 4 61  4. “It is necessary to keep my knees together at all times.”  5. “When I sleep, I should keep a pillow between my legs.” Rationale: 1., 2., 3. & 5. Correct: These are appropriate actions to prevent hip prosthesis dislocation. Until the hip prosthesis stabilizes it is necessary to follow these instructions for proper positioning to avoid dislocation. 4. Incorrect: The knees should be kept apart at all times, to prevent dislocation. 60. The client presents to the emergency department with no known injury and back pain so severe they cannot walk. The client describes the pain as coming in waves. What should the nurse do first? o 1. Medicate for pain o 2. Obtain urine specimen o 3. Check the patellar reflex o 4. Provide gentle stretching maneuvers Rationale: 2. Correct: Yes, high suspicion for renal calculi 1. Incorrect: No, we must investigate the pain before we cover it up – pain is a symptom. 3. Incorrect: Not helpful in this situation 4. Incorrect: Not helpful- maybe harmful 61. The nursing supervisor is observing a nurse caring for a client with a chest drainage system receiving 20 cm of suction. The nursing supervisor recognizes proper procedure by the nurse when the nurse performs which action? Select all that apply.  1. Maintain chest drainage system below the client’s chest during transport.  2. Apply tape to the connection tubes.  3. Add sterile saline to suction control chamber to achieve 20 cm. Page 62 of 68 Day 4 65 leakage and bacterial invasion. 1. Incorrect: What does drinking distilled water have to do with it? Nothing 3. Incorrect: They thought they would throw this one in there, maybe they could get you into boiling that dialysate, and burn out the peritoneum so we don’t have to worry about this anymore we can go straight to hemo now. 4. Incorrect: Do you have an arteriovenous fistula? Not with peritoneal dialysis. That goes with hemodialysis. 64. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client’s spouse asks the nurse about the reason for having two chest tubes. The nurse’s response is based on the knowledge that the lower chest tube is placed to: o 1. Remove air form the pleural space. o 2. Create access for irrigating the chest cavity. o 3. Evacuate secretions from the bronchioles and alveoli. o 4. Drain blood and fluid from the pleural space. Rationale: 4. Correct: Fluid will drain down and the lower chest tube is for drainage of blood and fluid from pleural space. 1. Incorrect: The top chest tube will remove air from pleural space. 2. Incorrect: No, a nurse will not irrigate the chest cavity. 3. Incorrect: No, chest tube is in pleural space. 65. The nurse is caring for a female that is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do? o 1. Allow the client to discuss her fears and encourage her to talk with her physician. o 2. Tell her the good things that she will able to do without more children. o 3. Explain to the client that her ovaries can be frozen for egg Page 66 of 68 Day 4 67 harvesting at a later time. o 4. Advise the client to put off having the surgery until she is sure. Rationale: 1. Correct: This may be anticipatory grieving and being scared. Let the person talk and encourage them to talk again to the physician. They need reassurance that they are making the right decision. 2. Incorrect: This is not her fear and not helpful in this situation. 3. Incorrect: Not an appropriate answer and we don’t freeze ovaries. 4. Incorrect: The cancer is already advanced stages, will the waiting help her survive?