NCLEX- CRIS-TEST I EXAM QUESTIONS AND ANSWERS LATEST
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A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the
nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - CORRECT ANSWERS 1)
Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac
output; fetal pressure on inferior vena cava reduced
4) Implementation: outcome not desired; elevation of legs will increase venous return, but
fetal pressure on vena cava will prevent blood return to heart
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care,
the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the
MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - CORRECT
ANSWERS 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk
of aspiration; cuff position and pressure should be assessed frequently; swallowing and
breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
