Test Bank For Emergency Nursing NCLEX questions and answers, Study Guides, Projects, Research of Nursing

Download Test Bank For Emergency Nursing NCLEX questions and answers and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Test Bank For Emergency Nursing NCLEX questions and answers 1. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation. 2. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides discharge instructions to a patient and his family. Which misunderstanding by the family indicates the need for more detailed information? A. The patient may resume normal home activities as tolerated but should avoid physical exertion and get adequate rest. B. The patient should resume a normal diet with emphasis on nutritious, healthy foods. C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely resolved. D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions. 3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which of the following actions should the nurse take? A. Restrict visiting hours and ask the family to limit visitors to two at a time. B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed. C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family. D. Contact the physician to report the unusual rituals and activities. 4. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prior to discharge. B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and scheduled for an angiogram. C. A patient with unstable angina being closely monitored for pain and medication titration. D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds were filled. 5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks the purpose of this medication. Which of the following statements by the nurse is correct? A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection. B. Glucagon treats hypoglycemia resulting from insulin overdose. C. Glucagon treats lipoatrophy from insulin injections. D. Glucagon prolongs the effect of insulin, allowing fewer injections. 6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct placement of the conductive gel pads? A. The left clavicle and right lower sternum. B. Right of midline below the bottom rib and the left shoulder. C. The upper and lower halves of the sternum. D. The right side of the sternum just below the clavicle and left of the precordium. 7. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain. The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or buzzing sound heard in one or two quadrants." Which of the following statements is correct? A. The frequency and intensity of bowel sounds varies depending on the phase of digestion. B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched. C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal. D. All of the above. 8. A patient arrives in the emergency department and reports splashing concentrated household cleaner in his eye. Which of the following nursing actions is a priority? A. Irrigate the eye repeatedly with normal saline solution. B. Place fluorescein drops in the eye. C. Patch the eye. D. Test visual acuity. 9. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about which of the following findings? A. Complaints of pain during repositioning. B. Scant bloody discharge on the surgical dressing. C. Complaints of pain following physical therapy. D. Temperature of 101.8 F (38.7 C). 10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writes orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be included? A. Notify the physician. B. Restrain the patient's limbs. C. Position the patient on his/her side with the head flexed forward. D. Administer rectal diazepam. 11. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed. 12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient? A. Numbness in hands and feet. B. Muscle cramping. C. Hypoactive bowel sounds. D. Positive Chvostek's sign. Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverses rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin injections on subcutaneous fat. 6. Answer: D One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left of the precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are placed over the pads. Options A, B, and C are not consistent with the position of the heart and are therefore incorrect responses. 7. Answer: D All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds, which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal. 8. Answer: A Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed. 9. Answer: D Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperatively is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody drainage on the surgical dressing is a result of normal healing. 10. Answer: B During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing the seizure. Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying position with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking the airway. Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure. 11. Answer: C Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non- urgent. 12. Answer: C Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of hypocalcemia. 13. Answer: A A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low PCO2. 14. Answer: A The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient's anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication. 15. Answer: A and B Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels. 16. Answer: B An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. An IV line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line. 17. Answer: D Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death. 18. Answer: B, C, and D Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following amniotomy, cervical checks are minimized because of the risk of infection 19. Answer: D An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia. 20. Answer: A All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Infant car seats should never be placed in the front passenger seat. Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital. a. Blurred vision b. Anorexia c. Diarrhea d. Fever Answer: c Rationale: Diarrhea is by far the most common early sign of colchicine toxicity. When given in the acute phase of gout, the dose of colchicine is usually 0.6 mg (PO) q hr (not to exceed 10 tablets) until pain is relieved or gastrointestinal symptoms ensue. 9. A client has chronic dermatitis involving the neck, face and antecubital creases. She has a strong family history of varied allergy disorders. This type of dermatitis is probably best described as a. Contact dermatitis b. Atopic dermatitis c. Eczema d. Dermatitis medicamentosa Answer: b Rationale: Atopic dermatitis is chronic, pruritic and allergic in nature. Typically it has a longer course than contact dermatitis and is aggravated by commercial face or body lotions, emotional stress, and, in some instances, particular foods. 10. Skip 11. Skip 12. The nurse would expect to find an improvement in which of the blood values as a result of dialysis treatment? a. High serum creatinine levels b. Low hemoglobin c. Hypocalcemia d. Hypokalemia Answer: a Rationale: High creatinine levels will be decreased. Anemia is a result of decreased production of erythropoietin by the kidney and is not affected by hemodialysis. Hyperkalemia and high base bicarbonate levels are present in renal failure clients. 13. A 24-year-old client is admitted to the hospital following an automobile accident. She was brought in unconscious with the following vital signs: BP 130/76, P 100, R 16, T 98F. The nurse observes bleeding from the client's nose. Which of the following interventions will assist in determining the presence of cerebrospinal fluid? a. Obtain a culture of the specimen using sterile swabs and send to the laboratory b. Allow the drainage to drip on a sterile gauze and observe for a halo or ring around the blood c. Suction the nose gently with a bulb syringe and send specimen to the laboratory d. Insert sterile packing into the nares and remove in 24 hours Answer: b Rationale: The halo or "bull's eye" sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result. 14. A 24-year-old male is admitted with a possible head injury. His arterial blood gases show that his pH is less than 7.3, his PaCO2 is elevated above 60 mmHg, and his PaO2 is less than 45 mmHg. Evaluating this ABG panel, the nurse would conclude that a. Edema has resulted from a low pH state b. Acidosis has caused vasoconstriction of cerebral arterioles c. Cerebral edema has resulted from a low oxygen state d. Cerebral blood flow has decreased Answer: c Rationale: Hypoxic states may cause cerebral edema. Hypoxia also causes cerebral vasodilatation particularly in response to a decrease in the PaO2 below 60 mmHg. 15. Skip 16. A client is admitted following an automobile accident in which he sustained a contusion. The nurse knows that the significance of a contusion is a. That it is reversible b. Amnesia will occur c. Loss of consciousness may be transient d. Laceration of the brain may occur Answer: d Rationale: Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness, retrograde amnesia, and is generally reversible. 17. A client with tuberculosis is given the drug pyrazinamide (Pyrazinamide). Which one of the following diagnostic tests would be inaccurate if the client is receiving the drug? a. Liver function test b. Gall bladder studies c. Thyroid function studies d. Blood glucose Answer: a Rationale: Liver function tests can be elevated in clients taking pyrazinamide. This drug is used when primary and secondary antitubercular drugs are not effective. Urate levels may be increased and there is a chemical interference with urine ketone levels if these tests are done while the client is on the drug. 18. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the client's ear? a. Artificial nails b. Vasodilation c. Hypothermia d. Movement of the head Answer: c Rationale: Hypothermia or fever may lead to an inaccurate reading. Artificial nails may distort a reading if a finger probe is used. Vasoconstriction can cause an inaccurate reading of oxygen saturation. Arterial saturations have a close correlation with the reading from the pulse oximeter as long as the arterial saturation is above 70 percent. 19. While on a camping trip, a friend sustains a snake bite from a poisonous snake. The most effective initial intervention would be to a. Place a restrictive band above the snake bite b. Elevate the bite area above the level of the heart c. Position the client in a supine position d. Immobilize the limb Answer: a Rationale: A restrictive band 2 to 4 inches above the snake bite is most effective in containing the venom and minimizing lymphatic and superficial venous return. Elevation of the limb or immobilization would not be effective interventions. 20. There is a physician's order to irrigate a client's bladder. Which one of the following nursing measures will ensure patency? a. Use a solution of sterile water for the irrigation b. Apply a small amount of pressure to push the mucus out of the catheter tip if the tube is not patent c. Carefully insert about 100 mL of aqueous Zephiran into the bladder, allow it to remain for 10 hour, and then siphon it out d. Irrigate with 20mL's of normal saline to establish patency Answer: a Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness. 28. A nursing assessment for initial signs of hypoglycemia will include a. Pallor, blurred vision, weakness, behavioral changes b. Frequent urination, flushed face, pleural friction rub c. Abdominal pain, diminished deep tendon reflexes, double vision d. Weakness, lassitude, irregular pulse, dilated pupils Answer: a Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia. 29. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then a. Discarded, then the collection begins b. Saved as part of the 24-hour collection c. Tested, then discarded d. Placed in a separate container and later added to the collection Answer: a Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours. 30. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to a. Hypoextend the vertebral column b. Hyperextend the vertebral column c. Decompress the spinal nerves d. Allow the client to sit up and move without twisting his spine Answer: b Rationale: The purpose of the tongs is to decompress the vertebral column through hyperextending it. Both (a) and (c) are incorrect because they might cause further damage. (d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated. 31. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown b. Set alarms on the oximeter to at least 100 percent c. Identify if the client has had a recent diagnostic test using intravenous dye d. Remove the sensor between oxygen saturation readings Answer: c Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings. 32. A client being treated for esophageal varices has a Sengstaken- Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to a. Check that a hemostat is at the bedside b. Monitor IV fluids for the shift c. Regularly assess respiratory status d. Check that the balloon is deflated on a regular basis Answer: c Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention. 33. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be a. Ambulation as desired b. Bedrest in supine position c. Up ad lib and right side-lying position in bed d. Bedrest in Fowler's position Answer: d Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward. 34. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is a. pH 7.49, HCO3 24, PCO2 46 b. pH 7.49, HCO3 14, PCO2 30 c. pH 7.26, HCO3 24, PCO2 46 d. pH 7.26, HCO3 14, PCO2 30 Answer: d Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg. 35. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to a. Correct the hyperglycemia that occurs with acute renal failure b. Facilitate the intracellular movement of potassium c. Provide calories to prevent tissue catabolism and azotemia d. Force potassium into the cells to prevent arrhythmias Answer: b Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed. This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion. 36. Skip 37. Skip 38. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care? a. Edema of the stoma b. Mucus in the drainage appliance c. Redness of the stoma d. Feces in the drainage appliance Answer: d Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus