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NCLEX RN Practice Test (ALL PASSING LEVEL Qs) with
Rationales.
nurse does ED triage. unemancipated minor requests treatment. registration clerk states they need guardian's consent for treatment. which is the nurse's next action?
- triage after guardian consent obtained
- ask minor about medical reason for seeking treatment
- request HCP perform medical screening exam
- notify nursing supervisor - Correct Answer ask the minor about the medical reason for seeking treatment (wrong, picked d) rationale: unemancipated minors may consent to medical treatment if they have specific medical conditions- pregnancy/STI/substance abuse/mental health, not appropriate for nurse to notify nursing supervisor before assessing situation and determining whether consent is required nurse makes med surg unit assignments. LPN assigned to client with localized herpes zoster. LPN tells nurse "i have never had chickenpox" which response by nurse is most appropriate?
- use standard precautions when caring for this pt
- you will be fine, airborne precautions needed
- your client assignment will be changed
- why are you concerned about providing care for this pt? - Correct Answer your client assignment will be changed (wrong, picked a) rationale: localized herpes zoster is shingles, if you care for pt with herpes zoster you could get chickenpox from them caring for pregnant and postpartum pts. which client does the nurse see 1st?
- 6wks gestation, LPN can't get fetal heart tones with doptone
- 5 days postpartum, bright red bloody discharge
- 22 wks gestation, feels fetal movement 4times per hour
- 2 days postpartum, has urinary incontinence - Correct Answer 5 days postpartum pt reporting bright red, blood discharge (correct) rationale: bloody discharge (rubra lochia) should only last 1 - 3 days - need to monitor amount and color in addition to vital signs, fetal heart tones can't be heard until 8 - 12 wks, less than 3 fetal movements in 1 hour could indicate fetal issue, urinary incontinence is normal during postpartum- teach kegels pt has CLL is scheduled for bone marrow aspiration and biopsy. pt says, "i'm frightened i haven't had this test before and i don't know what to expect" which statements will nruse include when responding to pt's concerns? SATA
- we will move you to operating room where test is always performed
- bone in the front of the chest will be used for biopsy
- a tight pressure dressing will be placed over test site after procedure
- you will not feel any discomfort as the local anesthetic is injected
- risk of bleeding present, so will monitor test site frequently - Correct Answer tight pressure dressing placed over testing site after procedure & there is a risk of bleeding, so we will monitor the test site frequently rationale: bone marrow aspiration/biopsy can be done in pt room or a treatment room not OR, don't use sternum for biopsy, pressure dressing helps with bleeding, sting/discomfort during biopsy, can cause bleeding nurse speaks with pt and spouse who have been undergoing family counseling. pt's spouse states " you never take any responsibility for the messes you always cause" which response by nurse is best?
- why do you say that?
- blaming is not effective
- let's focus only on positives
- when is the last time you two had a vacation - Correct Answer blaming isn't effective (wrong, picked c) rationale: don't ask why, telling them blaming isn't effective helps keep focus on both people, "only" isn't a good word
pt diagnosed with malnutrition has continuous enteral feedings through newly placed gastrostomy tube. which actions will nurse include in plan of care? SATA
- cover insertion site with adhesive bandage
- add 8 hours of feeding to bag at a time
- rotate gastrostomy tube 360 degrees once daily
- auscultate for whoosh of air through gastrostomy tube
- check for slight in and out movement of gastrostomy tube - Correct Answer rotate gastrostomy tube 360 degrees once daily & check for slight in and out movement of gastrostomy tube rationale: insertion site should be covered with sterile bandage to reduce infection risk until stoma is healed, only 4 hours of enteral feeding added to bag at a time to reduce bacterial contamination, rotate 360 degrees daily to reduce risk of skin irritation and breakdown, don't insert air for gastrostomy rube assessment, slight in/out indicates tube isn't embedded in wall of stomach nurse asses pt for potential spousal abuse. nurse is most concerned if pt makes which statement?
- it's my fault because I push my spouses buttons
- my spouse and i often disagree on many things
- we have talked about divorce multiple time
- i used to be so happy, but now I am not - Correct Answer it's my fault because i push my spouse's buttons (correct) rationale: spousal abuse victim accept blame often and feel helpless and compliant, should also follow up on option D but not the most concerning thing nurse has guillian barre pt. flaccid paralysis of both legs, history of coronary artery bypass 3 wks ago, 20 yr history of HTN and high cholesterol, recently diagnosed with T2DM. nurse prepares to apply anti-embolism stockings to both legs. which priority action does nurse implement?
- bilateral pretibial edema
- palpate both calves for pain
- ask the reason for stocking application
- bilateral pedal pulse strength - Correct Answer bilateral pedal pulse strength (correct) rationale: some edema is expected when immobile and stocking will reduce the edema, VTE would be a contraindication for stocking but calf pain isn't always present with DVT and pain is a psychosocial idea, best indication of peripheral arterial disease and circulation is to monitor pedal pulses, decreased circulation would be contraindicated for stocking so need to assess ASAP pt approaches traige desk reporting exposure to chemicals after truck overturn. pt has powder and unknown liquid substance on clothes. pt is diaphoretic and having difficulty breathing. which action does nurse take first?
- escort pt to decontamination room
- notify HCP
- put on appropriate PPE
- deliver high flow oxygen via mask - Correct Answer put on appropriate PPE (wrong, picked a) rationale: first priority is to protect self with PPE, then escort to room to prevent spread, then call HCP, then oxygen 50mg/kg ampicillin every 6 hours. 18 lbs. available in 125mh/5ml. how many ml per dose? - Correct Answer 16 ml most appropriate place to obtain capillary glucose sample? - Correct Answer outside of pointer finger During a urinary bladder catheter insertion with a size 16 catheter on the 68 - year-old male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take?
- Withdraw the catheter and apply more lubricant.
- Instruct the client to take a deep breath and bear down.
- Stop catheter insertion and instruct client to take deep breaths.
- Withdraw the catheter and notify the health care provider. - Correct Answer stop insertion and instruct pt to take deep breaths (Correct)
rationale: take deep breaths will relax urethral muscles and allow passage through prostate gland, valsalva maneuver will not allow passage, don't complete withdraw cath and then re-insert this increases risk of infection, determine is there is an issue before calling HCP ED assess pt with tonic clonic epilepsy. pt's spouse says pt is taking phenytoin as prescribed, but hasn't been feeling well lately. which pt observation is most concerning?
- red brown urine, constipation
- acne, hirsutism, gingival hyperplasia
- ataxia, slurred speech, nystagmus
- left arm in sling, walking with limp - Correct Answer ataxia, slurred speech, nystagmus (wrong, picked b) rationale: slurred speech and ataxia are airway concerns = highest priority over anything else pt on IV midazolam after procedure. blood pressure is increasing, oxygen sats falling, now 1/10 pain and nausea, arouses to commands now. best action?
- recheck BP in 15 mins
- administer ondansetron
- 12 lead EKG
- assist client to get dressed - Correct Answer recheck BP in 15 mins (wrong, picked b) rationale: midazolam causes hypotension and the elevated BP puts patient at risk for stroke, appropriate to assess BP every 15 mins because it is still increasing = priority nurse admits pt postpartum, instruction about postpartum care have been effective if which statement is given?
- i will call for assistance the first time i want to get out of bed
- i can expect to pass clots the size of golf balls for the first 24 hrs
- i will use lanolin on my nipple while breast feeding the baby
- i will allow my baby to not suck on nipple for more than 5 mins each breast - Correct Answer i will call for assistance the first time I want to get out of bed (wrong, picked b)
rationale: want clots to be smaller than a golf ball, ESRD pt prescribed HD 3x/week. after 2 wks of treatment pt says, "i have had a headache when dialysis finishes. is that normal?" which is the most appropriate response by the nurse?
- i have seen this a lot in pts. don't worry too much.
- headaches may occur at the beginning of treatment and should improve over time
- have you experienced any headaches similar to these in the past
- why are you so worried about it? - Correct Answer headaches may occur in the beginning of treatment and should improve over time (correct) rationale: headache, nausea, fatigue are normal after HD due to disequillibrium from rapid removal of electros from blood, address here and now not the past headaches nurse instructs student about correct way to set up sterile field. teaching was effective if which action is observed?
- supplies placed at edge of sterile field
- gown and gloves worn at all times
- sterile field is above waist level
- supplies opened with sterile gloves - Correct Answer sterile field set up above waist level (correct) 3 serious safety events have occurred on the unit between 0730 - 0800 in last month, last one happened because oncoming nurse didn't know pt was on IV insulin, which is priority action for nurse supervisor to take?
- implement mandatory bedside report
- discuss unsafe nursing practices with local media
- delay action until risk manager has full investigation done
- ask another nurse manager for ideas - Correct Answer implement mandatory bedside reporting (correct) rationale: need to take action now, bedside report promotes accountability, decreases errors, involve hospital risk manager but need to do something now
nurse completes documentation for pt and realizes entry was placed under wrong pt medical record. which action by nurse is most appropriate?
- complete incident report and place copy in pt's medical record
- draw single line through each line of incorrect entry and write new note explaining what happened
- use correction fluid to delete wrong and write in space note was obliterated for confidentiality
- copy note into correct record and indicate it was erroneously put in wrong chart - Correct Answer draw a single line through each line of the incorrect entry and write new note explaining what occurred (wrong, picked a) terminally ill pt reports that DNR was initiated. pt's family is not accepting this wish. which is best action?
- reassure pt that things will work themselves out
- allow next of kin to make final decisions
- schedule meeting with pt and family
- contact social worker - Correct Answer schedule meeting with pt and family (correct) rationale: family needs to acknowledge and accept pt wishes, meeting will allow this, try talking with pt and family before social worker gets involved rehab center for pts with spinal cord injuries UAP's are being taught about care. most important for nurse to implement?
- pts may appear angry at times
- obtain pt's permission before touching pt
- most pt's arrive believing they will walk out of here
- personnel in this place often need counseling - Correct Answer obtain pt's permission before toughing them (correct) rationale: looking for information on how to provide care = not touching before asking/telling telemetry nurse notifies med surg that they need to give them a pt. which pt should go to med surg unit?
- mag of 1.
- scheduled for cardiac cath next morning
- digoxin of 2.
- chest discomfort reported during cardiac stress test - Correct Answer mag of 1. (wrong, picked d) rationale: mag should be 1.3-2.1 so is stable, cardiac cath isn't stable- need to monitor rhythms, digoxin level is 0.5-2.0 so this is unstable and high, chest discomfort during test indicates poor response to workload and is unstable pt HCP prescribes metoclopramide to be given for pt 30mins before cisplatin is given. pt asks nurse why metoclopramide is given. what is best response?
- meto will prevent or reduce side effects caused by cis
- meto increases cis effectiveness
- cis prevents or reduces meto side effects
- cis increases meto effectiveness - Correct Answer meto prevents or reduces side effects of cis (correct) rationale: meto (helps with stomach/esophagus issues) is prescribed to reduce cis side effects (antineoplastic) med surg nurse to patient ratio is 1:10. first action by nurse?
- document situation in writing
- refuse pt assignment
- delegate tasks to LPN
- notify nursing supervisor - Correct Answer notify the nursing supervisor (correct) rationale: this is the priority action of this unsafe situation, this will allow other nurses to be floated to this unit to help pt with MS says, "i have poor concentration and difficulty pronouncing words" nurse notes pt has slow speech and is slurred. which pt statement indicates further teaching is needed?
- sit up straight when i talk and i will feel confident
- i will turn TV off when speaking and look at who i am talking to
- during conversation i will build up to my most important points
- if words fail me, i will draw a picture - Correct Answer during a conversation, i will carefully build up to my most important points (correct) rationale: pt needs to be taught to make most important points first so fatigue doesn't onset before them young adult scheduled for emergency appendectomy. HCP explains the procedure and now the pt states "no one is removing any organs from my body because it is against my religious beliefs. i'm leaving" the pt's mom insist the pt gets the operation. which response does nurse make to pt?
- i am going to apply restraints
- let us contact the chaplain to mitigate situation
- IV diazepam will help to calm your nerves before the procedure
- it is your decision to reduce medical treatment - Correct Answer it is your decision to refuse medical treatment (correct) rationale: competent pt has the right to make personal choices without interference, diazepam is a chemical restraint!!! LPN says to RN, " you may want to check on pt recently recently diagnosed with pancreatic cancer. i'm not sure how well things are going" nurse enters room and finds pt quietly looking out the window. pt doesn't look at the nurse. which is the most appropriate response by the nurse?
- sleep problems are common during stressful times. have you been sleeping?
- tell me what you know about your diagnosis and the treatment you will receive
- how would you describe your overall health status up to this time in your life?
- how have you handled any health problems you experienced in the past - Correct Answer tell me what you know about your diagnosis and the treatment you will receive (wrong, picked d) rationale: most important to determine the pt's perception of health problem and this is an open ended questions, asking about coping with past problems doesn't address the
current problem, overall health status may influence coping but this option doesn't address concern nurse provides care to pt diagnosed with depression and anxiety. pt states " i feel overwhelmed because i'm the only caregiver of my 2 kids" which is the nurse's best response?
- do you participate in any religious or spiritual activities?
- what can we do to take your mind off things?
- you don't plan on having more kids do you?
- why do you not work outside the home? - Correct Answer do you participate in any religious or spiritual acitivities? (incorrect, picked b) rationale: spirituality/religion have potential to influence how people understand their lives purpose. distraction isn't always the best technique - assess coping mechanisms stroke pt admitted to rehab center. left sided pronator drift, left extremity dorsiflexion, bumps into left wall when sitting in chair/wheelchair. most important action for nurse to take?
- place favorite watch on left wrist
- provide written list for pt to follow during morning care
- instruct to choose a dress for the day
- position client so the right side faces the door of the room - Correct Answer position the pt so the right side faces the door of the room (correct) rationale: pt has right sided brain stroke with left sided neglect. so the pt can't see out of the left side of both eyes, safety is priority to enhance this the best vision vision for pt would be facing door nurse prepares to give morphine. which action does nurse take first?
- verify name and DOB
- document amount used on med record
- determine if pt has a responsible driver
- ensure call light and belongings in reach - Correct Answer verify name and DOB (correct)
rationale: need to verify identity first before giving med RA pt prescribed etanercept subQ weekly. reports joint swelling, symmetrical joint pain, deformities of both hands. which finding does nurse report to HCP?
- wbc 14
- c-reactive protein 1.
- hgb 9
- sedimentation rate 22 - Correct Answer wbc of 14 (wrong, picked c) rationale: wbc of 14 could indicate active infection which would contraindicate etanercept, other findings are expected, c-reactive <10 (if >10 = infection), sedimentation rate 0 - 22 confused pt, soft wrist and ankle restraints on. care is effective if which actions are documented? SATA
- restraints secured tightly to skin
- pt placed in room near nurses station
- restraints attached to side rails of bed
- informed consent obtained from spouse
- alert and oriented *
- placed in prone position - Correct Answer placed near nursing station & informed consent from spouse rationale: don't want them secured tightly, attached to bed frame not side rails, discontinue restraints when alert/oriented, prone position would increase risk of suffocation nitroprusside 0.3mcg/kg/min, 176lbs, concentration of nitroprusside is 50mg/250ml. what is ml/hr rate? - Correct Answer 7.2 ml/hr pt gets blood transfusions and has hemolytic reaction, what assessments findings? SATA
- hypotension
- low back pain
- wet breath sounds
- urticaria
- severe SOB - Correct Answer hypotension & low back pain & fever rationale: wet breaths sounds if fluid overload, hives for allergic reaction, SOB for circulatory overload getting blood through PICC. what would require intervention?
- discards 1 ml of blood before obtaining sample
- uses 10 ml syringe to flush through port of the cath
- applies clean gloves to beginning the procedure
- uses push pause technique to flush cath - Correct Answer nurse discards 1 ml of blood prior to obtaining the blood sample (wrong, picked d) rationale: should discard 3 - 5ml of blood with IV fluids or meds, 10 ml syringe is recommended to reduce pressure during flush, clean gloves used with PICC, push pause reduces risk of clot formation and PICC damage community health nurse conducts suicide prevention program. high risk groups for suicide. what would indicate further teaching?
- adolescents at risk for suicide
- depressed pt at risk for suicide
- history of previous suicide attempts put people at risk for suicide
- people grieving a loss for 9 mths at risk - Correct Answer people grieving a loss for 9 months are at risk (correct) rationale: grieving process can occurs for up to 3 yrs (abnormal cardiac rhythm) diastolic heart failure pt. which is the most appropriate action for nurse to take?
- digoxin 0.25mg IV
- instruct pt to take deep breath and hold it
- assess LOC and orientation
- auscultate posterior chest - Correct Answer assess LOC and orientation (wrong, picked a) rationale: LOC and orientation are best indicators regarding effect of atrial fibrillation on cardiac output, changes in LOC/alertness is earliest indicator of poor cardiac output nurse provides care for pt underwent vagotomy with antrectomy to treat duodenal ulcer. post op pt develops dumping syndrome. which statement indicates further teaching needed?
- i am able to eat roll or bread at dinner
- i usually eat smaller meals, about 6 per day
- i need to recline after meals to help digestion
- i should avoid drinking fluids with my meals - Correct Answer i am able to eat a roll or bread at dinner (wrong, picked c) rationale: carbs increase risk of dumping syndrome, smaller/frequent meals decrease risk for dumping syndrome, should recline after meals, should avoid fluids with meals family member of pt diagnosed with pneumothorax, "i think something is wrong with that drainage device. it just got very noisy" nurse observes bubbling in underwater seal is continuous compared to several hours ago. which action should nurse take first?
- clamp chest tube at insertion site
- add sterile water to underwater seal chamber
- notify HCP
- observe connections of drainage system - Correct Answer observe the connections of the drainage system (wrong picked a) rationale: a leak in drainage system can cause continuous bubbling so assess equipment first when assessing incision of pt 2 days post op, shiny pink area with underlying bowel visible. which action does nurse implement?
- cover area with sterile gauze soaked in NS
- cleanse wound with hydrogen peroxide and apply a sterile dressing
- pack open area with sterile 3/4 in gauze soaked in NS
- apply antibacterial ointment and cover with clear adhesive dressing - Correct Answer cover area with sterile gauze soaked in normal saline (correct) rationale: experiencing evisceration, so cover site immediately and then contact HCP nurse provides care for pt who is prescribed assist control mechanical ventilation with PEEP of 5. which actions will nurse include in plan of care? SATA
- strict handwashing before suctioning
- brush teeth every 12 hrs
- elevate HOB 20 degrees
- administer pantoprazole IV daily
- changing pt position every 2 hr - Correct Answer strict handwashing before suctioning & administer pantoprazole IV daily & change pt position every 2 hrs rationale: hand hygiene reduces risk of VAP, pantoprazole decreases risk of aspiration, re-positioning reduces risk of atelectasis/pneumonia/skin breakdown, oral care every 8 hrs is correct, HOB elevated at least 30 degrees nurse assess pt with meinere disease. pt states " i take my prescribed meds regularly, but I continue to have episodes of vertigo" which response by nurse is most important?
- tell me about your diet
- how are things going at work
- when was meniere disease diagnosed
- what were the results of your last blood test - Correct Answer tell me about your diet (wrong, picked c) rationale: diet factor that could lead to med interaction may be interfering nurse is supervising UAP immediately intervene and provide assistance if which scope of practice violation observed?
- routine blood glucose test
- urine pregnancy test
- older client assistance with feeding
- restarts IV fluids - Correct Answer restarts IV fluids (correct) nurse determines tracheostomy requires suctioning. which action does nurse take first?
- elevated HOB to 90
- quickly insert suction cath
- preoxygenate pt
- put on clean gloves - Correct Answer preoxygenate pt (correct, picked a) rationale: place in semifowler's not high fowlers, need to prep before suction, sterile gloves for suctioning, preoxygenate so no hypoxia nurse evaluates care assignments. RN intervenes is LPN has what pt?
- methylprednisolone for lumbar radiculopathy
- racemic epinephrine for croup
- ketorolac for pleurisy
- tamsulosin for BPH - Correct Answer racemic epinephrine for croup (correct) rationale: requires airway/breathing assessment nurse reviews AKI records. which lab value is most important?
- fasting blood glucose
- uric acid
- protein
- urine specific gravity - Correct Answer urine specific gravity (correct) rationale: USG is a good indicator of fluid volume and circulation nurse gets call "i just go to my elderly parents house, i think a heat stroke has occurred, air conditioning isn't working, house is very hot" adult child reports parent is confused, very thirsty, nauseated, in pain. most appropriate action?
- is sweat is present, heat stroke hasn't occurred
- give cool fluids to drink immediately
- what med does your parent take daily
- remove any excess clothing immediately - Correct Answer remove any excess clothing immediately (correct) rationale: removing clothes will begin cooling process to enhance circulation, at risk for aspiration due to confused mental status so no fluids by mouth pt with sudden onset of left sided facial droop and slurred speech at home. left sided muscle weakness seen too. most important question to ask?
- what over the counters does parent take
- what was parent doing when symptoms began
- when did you notice onset of your parent's symptoms
- does your parent have a history of high blood pressure - Correct Answer when did you notice the onset of your parent's symptoms? (correct) rationale: time is so important when providing care to pt who experiences an ischemic stroke, thrombolytic therapy has 4.5-6hr time frame BMI of 16.1, priority action of nurse?
- document pt's BMI
- decrease caloric intake to 1200 cals/day
- confer with dietitian
- plan return visit in 1 week - Correct Answer confer with dietitian (correct) rationale: low BMI needs dietitian <18.5 increased risk for nutritional problems head on collision with immediate loss of consciousness. first action by nurse?
- GCS score
- bilateral BP
- check bilateral pupillary response to light
- determine oxygen sat levels - Correct Answer determine oxygen saturation levels (wrong, picked c) rationale: ABCs!!!!!!! nurse discusses plan of care with student who says "i know pt is from another country, but the pt could at least look at me when i'm talking." which response is best?
- i am sorry they made you feel that way
- pt doesn't look at me when i speak either
- eye contact may be a sign of arrogance in their country
- i will ask the family if anything is bothering the pt - Correct Answer eye contact may be a sign of arrogance in the pt's country (correct( pt brough to ED with dry mouth, frequent urination, extreme thirst, no fluid intake for last 8hrs. may not have taken insulin in last couple of days. which prescription should nurse do 1st?
- administer 10meq potassium chloride orally
- begin regular insulin
- obtain 12 lead ekg
- begin infusion of 0.9NS - Correct Answer begin infusion of 0.9NS (correct) rationale: this pt is in DKA with the continuous diuresis they are at risk for fluid volume deficit so start fluids to help circulation, would be hyperkalemia not hypokalemia so no KCL, insulin doesn't help ABCs older adult pt who is diagnosed with fractured ulna who is falling frequently. which pt statements require nurse to collect more info? SATA
- i keep my bedroom pitch black at night
- my adult child secured all cords against baseboards
- bottoms of shoes are rubber
- sister gave me a cane before she died
- i have my vision checked every 3 yrs
- i prefer my pants to fit loosely around waist - Correct Answer keep bathroom pitch black at night, sister gave her cane, vision checked every 3 yrs, prefer pants to fight loosely around waist rationale: want rubber bottoms and cord secured to decrease falls, want a night light and make sure cane is proper height and need exams every 1 - 2 yrs for elderly, want tighter pants transfermal fentaynl patch prescribed. which statement made by client indicates correct understanding?
- i should avoid placing heating pad over med patch
- if i develop fever, less med will be absorbed through skin
- med patch should be folded and put in trash
- i will leave old patch on for few hours after putting new one on - Correct Answer i should avoid placing heating pad over med patch rationale: heat will increase med absorption rate, fever increases absorption via skin, flush is down the toilet, don't have two patches on at once AIDs pt and nurse is doing discharge teaching. which would indicate effective teaching?
- i will contact HCP if bed sheets drenched with perspiration
- it is safe to share toothbrushes with others
- it is safe to not use condoms since we both have HIV
- i will be cured if i take sidocudine as prescribed by HCP
- i will not go to the fall festival - Correct Answer i will contact HCP if my bed sheets become drenched with perspiration & i will not go to fall festival rationale: increased risk of infection so wet sheets could be TB, avoid large crowds / don't share toothbrush, should still use condoms, can't cure AIDS HCP prescribes an increase in PN infusion rate and is infusing through PICC. priority action by nurse?
- assess hourly urine
- evaluate serum protein
- assess VS every 4 hrs
- evaluate AST test - Correct Answer assess hourly urine (wrong, picked b) rationale: pulls fluids into intravascular space leading to diuresis and fluid volume affects ABCs, PN is high in protein so monitor the protein level but not ABC concern dehydration pt, restless, difficulty breathing. bilateral basilar crackles. which action will nurse take first?
- place pt on 2L oxy by NC and auscultate lungs
- elevate HOB and stop IV infusion
- decrease IV flow rate and administer furosemide
- stop IV infusion and notify HCP - Correct Answer elevate HOB and stop IV infusion (correct) rationale: elevate HOB to allow for more open airway chest tube and pleural drainage system for treatment of right sided pneumothorax. suction control chamber is set at 20cm and tubing is attached to wall suction. what would nurse expect to find after chest tube insertion?
- bubbling in water seal chamber
- serosangenous drainage in the collection chamber
- fluctuation in suction control chamber during coughing
- one cm sterile water in the water seal chamber - Correct Answer bubbling in water seal chamber (wrong, picked b) rationale: water seal chamber bubbles due to pneumothorax - expected findings, anticipate nor drainage or scant with pneumo, flucuation expected in water seal chamber when forcefully coughs but not expected after initial insertion, 2cm sterile water in water seal chamber to prevent reentry of air nurse meets with parents of adolescent who present to annual health maintenance visit. parents voice concern about recently becoming clumsy and uncoordinated. which response by nurse is best?
- son might have ADHD
- i'll talk with HCP to assess for subtle motor dysfunction
- clumsiness is expected at this age
- may be an early sign of depression - Correct Answer son's clumsiness is expected at this age (wrong, picked b) rationale: adolescent males experience rapid physical growth leading to clumsy and uncoordinated nurse provides care for adolescent who reports arm pain after a fall, also sees bruises in multiple stages of healing. client was treated twice last month for reported back pain after 2 separate falls and a perforated eardrum. priority action?
- assess anxiety level
- use light tough to show support
- contact social services
- assess pain level - Correct Answer contact social services (wrong, picked d) rationale: history suggests abuse, law mandates nurse report known or suspected abuse to social services or law enforcement