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Question 1
Your client was diagnosed with an arterial embolus. The physician performed an emergency embolectomy. What is the nurse’s highest priority?
a. Administer anticoagulants b. Check pulses** c. Listen to breath sounds d. Offer pain medication
Rationale: Monitoring pulses below the occlusion site checks the circulation in the extremity. Correct answer: B Bloom’s level: Analysis (examine cause and effect) NCLEX: Physiological adaptation
Question 2
A type 1 diabetes mellitus student comes to the school clinic stating they do not feel well. Which symptoms require immediate intervention?
a. Deep, rapid respirations with long expirations, thirst and abdominal pain** b. Perspiration, BP 130/84 and blood glucose of 150 c. Regular depth respirations with frequent pauses, oliguria, and flushed skin d. Tired, BP of 110/60, and blood glucose 108
Rationale: Kussmaul’s respirations (deep, rapid respirations with long expirations) is an indicator of metabolic acidosis. The body is attempting to blow off carbon dioxide and acetone. Symptoms of ketoacidosis include extreme thirst, frequent urination and a fruity or acetone odor to the breath. Correct answer: A Bloom’s level: Analysis (processing more than two pieces of data to determine correct response) NCLEX: Physiological adaptation
Question 3
The nurse is caring for a pediatric client with 2nd^ and 3rd^ degree burns to his arms, abdomen, and legs. The nurse should assign the client to which of the following roommates?
a. A 2-year-old client with an unspecified temperature b. A 4-year-old client receiving treatment for Measles c. A 5-year-old client with sickle-cell disease ** d. A 7-year-old client undergoing VRE treatment
Rationale: The nurse should be concerned about the burn victim’s susceptibility to acquire an infection—sickle cell disease is not a communicable disease. Correct answer: C Bloom’s level: Analyze & Apply NCLEX Plan category: Safety and Infection Control
Question 4
Which of the following clients is not a good candidate for the influenza shot vaccination?
a. A 6-month-old male with normal development b. A 31-year-old pregnant female that is afebrile c. A 49-year-old male with a history of Guillain-Barré Syndrome ** d. A 63-year-old female with a history of DVT and anti-platelet therapy
Rationale: The influenza vaccine is contraindicated in people with a history Guillain-Barré Syndrome. Correct answer: C Bloom’s level: Evaluate NCLEX Plan category: Health Promotion
Question 5
A nurse is teaching a client the appropriate way to use a metered dose inhaler. The nurse recognizes that the client needs FURTHER teaching when observing the following:
a. The client takes a deep breath while depressing the inhaler. b. The client holds his breath for about 10 seconds, and then breathes out. c. The client waits 30 seconds before using the inhaler the second time.** d. The client rinses out his mouth after using the inhaler.
Rationale: The client should wait one minute (60 seconds) before using the inhaler the second time. The client’s wait time of 30 seconds indicates he needs further teaching. All other choices are correct ways to use an inhaler. Correct answer: C Blooms Level: Analyze
Question 6
NCLEX test plan: Pharmacological Therapies Which of these measures should be included to prevent the transmission of pulmonary tuberculosis?
a. Adequate and separate ventilation of rooms.** b. Strict hand washing. c. Use of surgical mask by the caregiver. d. Use of HEPA-filter mask by the patient.
Rationale: Pulmonary tuberculosis is an airborne disease that is spread from person to person by droplets when an infected person coughs, sneezes, speaks, sings, or laughs. Responses b, c, and d are not adequate interventions for the prevention of tuberculosis. Having rooms with adequate ventilation of non-recirculated air is the best plan. Answer: A
Blooms Level: Application NCLEX test plan: Safety and Infection control
Question 9
A client placed in isolation for Tuberculosis asks the nurse why staff and visitors must wear masks when in the patient’s room. What response by the nurse indicates understanding of TB isolation?
a. “Masks are part of the isolation uniform that everyone must wear.” b. “The mask protects staff and visitors from contracting the disease and passing it to others.”** c. “The mask protects you from the germs staff and visitors carry in the room.” d. “Why are staff and visitors wearing masks in your room? They don’t need to.”
Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. Airborne isolation consists of gown, gloves, and surgical mask. Correct answer: B. Bloom’s Taxonomy: Application NCLEX Category: Safe and Effective Care Environment (Subcategory: Safety & Infection Control)
Question 10
A nurse is assessing a client who complains of sudden shortness of breath and chest pain. The nurse notices the patient is breathing rapidly and heart rate has increased to 140 bpm. The nurse identifies these findings as s/s of which of the following?
a. asthma b. bronchitis c. COPD d. pulmonary embolism**
The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. Correct answer: D. Bloom’s Taxonomy: Application NCLEX category: Physiological Adaption
