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HURST REVIEW NCLEX-RN Readiness Exam 1 - Questions, Answered and well detailed Rationales

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HURST REVIEW NCLEX-RN Readiness Exam 1 - Questions, Answered and well detailed Rationales A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department ... nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)? 1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC) 4. Correct: A change in LOC is one of the earliest indicators of an elevated ICP. 1. Incorrect: Loss of pupillary reflexes is a late sign of increased ICP. Earlier pupil changes would include gradual dilation and pupils become sluggish in response to light. 2. Incorrect: This is a late sign of increased ICP. This pattern of respirations is characterized by an increase in depth and rate of respirations followed by a gradual reduction. 3. Incorrect: Cushing's triad is a very late presentation of brain stem dysfunction and manifest as bradycardia, hypertension, and bradypnea. It is seen when cerebral blood flow decreases significantly. This is a grave sign for a client with a head injury. It is related to a significant increase in ICP. Therefore, it is not one of the earliest indicators of an elevated ICP. It is a late sign and if intervention is not initiated, herniation of the brain stem is imminent, with death likely. What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung? 1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest. 1., 2., 3., & 4. Correct: A pleural effusion is a collection of fluid in the pleural space that moves to the bottom of the chest cavity when upright. The semi-Fowler's position allows the client to be in an upright position to promote drainage and facilitate ease of respirations by promoting lung expansion. Since lung expansion is compromised with a pleural effusion, the oxygen level should be assessed using an oxygen saturation monitor. The client's respiratory status should be assessed at least every 2 hours: respiratory rate, work of breathing, breath sounds, pulse oximetry. The development of kinks, loops, or pressure on the drainage tubing can produce back pressure, which may force fluid back into the pleural space or interfere with the drainage. 5. Incorrect: The closed drainage unit should be placed below the level of the client's chest to prevent drainage from flowing backward into the pleural space. A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse? 1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse 3. Correct: Lead may be found in the soil around rusted cars and can cause lead exposure. Old paint contains lead. Chips of paint may be consumed by young teething children. Old, run-down apartments may also have pipes which contain lead. Exposure to and consuming even small amounts of lead can be harmful. No safe lead level in children has been identified, and lead can affect nearly every system in the body. Mental and physical development can be negatively impacted by lead in the body. 1. Incorrect: Although the nurse does need to check immunizations, the hints in the stem indicate several problems that should direct the focus to lead poisoning, which is the priority. Immunization should be administered if the child is not on schedule, but consequences of lead poisoning is much more serious. 2. Incorrect: There was nothing in the stem indicating school problems. This would not take priority over lead exposure assessment. 4. Incorrect: Although poverty and poor housing conditions have been identified as environmental factors for potential abuse, the stem of this question does not provide additional cues that would indicate abuse. Assessment for lead poisoning would be the priority in this situation based on the environmental issues identified. The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen? 1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer. 2. Correct: The color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. Prostaglandins cause increased permeability in the sclera to aqueous fluid. So, as the prostaglandin agonist increases this activity, the outflow of aqueous fluid increases and the ocular pressure decreases. Administering the drops in the unaffected eye may result in a subnormal intraocular pressure. 1. Incorrect: This comment shows adequate understanding. The client should only treat the eye with the increased pressure. 3. Incorrect: This comment demonstrates that the client does understand the treatment regimen. Overmedicating the affected eye could reduce the intraocular pressure too much. 4. Incorrect: This comment shows understanding. The lashes in the eye being treated will lengthen as opposed to the untreated eye. The changes of the eyelashes (increased length, thickness, pigmentation and number of lashes) are typical with these eye drops and are viewed as a benefit by many clients. The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle? 1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again. 2. Correct: Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner. The risk of death or injury is highest at the time the abused person decides to leave the abusive relationship or shortly after leaving. 1. Incorrect: Just because the victim leaves does not guarantee that the abuser will not follow or find her. The threat of injury or death increases at the time the abused person leaves. This response is giving false reassurance to the abused person. 3. Incorrect: The client should be praised; however, there are risks with both leaving and staying. The client should be informed. The nurse should acknowledge the fear of staying in the relationship and guide the client to resources that can be used to help make informed decisions. 4. Incorrect: Leaving the home and the perpetrator do not guarantee cessation of violence. Again, this only provides false reassurance that the abuser will not find the client and inflict harm. To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed 1., 3., 4., & 5. Correct: The primary healthcare provider should be notified of any rhythm changes or report chest pain/discomfort. These could be signs of re-occlusion. Decreased urinary output (UOP) could be due to poor renal perfusion, which can result from decreased cardiac output and shock. Frequent VS and UOP measurements are needed. Flexion should be avoided at the catheter access site to allow time for the clot to stabilize and reduce the risk of bleeding and hematoma formation. The client should avoid lifting the buttocks off the bed because this increases pressure at the insertion site which increases the risk of hematoma formation/bleeding. 2. Incorrect: Assessments are needed more frequently than every 8 hours. Although policies may differ, assessment of the insertion site is usually every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly for 4 hours. More frequent monitoring may be required. During the assessment, the nurse should observe the catheter access site for bleeding or hematoma formation and should assess the peripheral pulses in the affected extremity. A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate? 1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration 4. Correct: Increasing hydration status via the administration of IV fluids is indicated in sickle cell crisis to increase that volume in the vascular space and subsequently decrease the vaso-occlusion from the sickling effects of the RBCs. The increased volume separates the sickled cells to reduce the clumping together of the cells. 1. Incorrect: While beneficial for many clients, a high protein, low fat diet provides no benefit during the crisis phase of sickle cell disease. Hydration to improve circulation is a priority due to the impairment or obstruction of blood flow caused by the sickled cells clumping together. 2. Incorrect: Thrombolytics are indicated for the lysis of existing clots and do not have a primary role in the treatment or management of sickle cell disease. The issue in sickle cell crisis is not clot formation but rather a clumping together of sickled cells that impairs or blocks circulation. 3. Incorrect: Sickle cell disease is characterized by sickling of RBCs, causing them to clump together and obstruct capillary blood flow, causing ischemia and possible tissue infarction. Increased risk of bleeding is not a concern. 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? 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. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs. 1., 2., 3. & 5. Correct: One of the most common problems after hip surgery is dislocation. Until the hip prosthesis stabilizes, it is necessary to follow these instructions for proper positioning to avoid dislocation. Flexion and movement of the leg on the affected side past midline should be avoided. 4. Incorrect: The knees should be kept apart at all times. This is called abduction and is needed to keep the new head of the femur (prosthetic device) in the acetabulum and therefore prevent hip dislocation until healing occurs and tissues are strong enough to hold the joint in place. The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents? 1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence. 2., 3. & 4. Correct: Letting the child do things on their own will promote a sense of self control and independence during this stage of autonomy versus shame and doubt. Finger foods allow for independence with eating and builds a sense of autonomy. At this age, the child becomes increasingly aware of separateness from the parent. The need is for the parent to be available for emotional support when needed. However, if emotional needs are inconsistently met or if the parent rewards clinging, dependent behaviors and withholds nurturing when the child demonstrates independence, feelings of rage and fear of abandonment may develop in adulthood. The support provided by the parent can lessen feelings of anxiety for the child when the emotional presence is needed. 1. Incorrect: Strict toilet training can result in retention of feces and constipation. In addition, strict toilet training practices before the child is ready can result in frustration and shame. 5. Incorrect: Assisting with all tasks will promote dependence. This does not give the child opportunities to perform age-appropriate tasks independently and gain a sense of autonomy. Notice the word "all"? This conveys a thought or concept that has no exceptions. Words such as just, always, never, all, every, none, and only are absolute and place limits on the statement that generally is considered correct. Statements including these words generally make the statement false as the statement is general and broad and does not allow for exceptions. The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority? 1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye. 4. Correct: If a foreign body is the result of explosion or blunt or sharp trauma, the eye should be protected from further damage by placing an eye shield over the eye (or if a shield is not available, a paper cup to prevent rubbing of the eye). Then make arrangements to transport the client for emergency care by an ophthalmologist. If movement of the unaffected eye creates movement in the affected eye, it may be necessary to cover the unaffected eye also to prevent further injury to the eye from movement. 1. Incorrect: Everting the eyelid and examining for a foreign body are not measures that should be performed before placement of eye shield. You should never attempt to remove a foreign body, so examination would not be needed at this point. 2. Incorrect: Measuring visual acuity is not a priority and is not performed before placement of eye shield. The goal is to protect the eye from further injury and reduce movement of the eye. The shield will help accomplish this goal. 3. Incorrect: Notifying immediately for transfer should not be done before placement of eye shield. The eye should be protected first to reduce further injury. The school nurse has identified a large outbreak of viral conjunctivitis among [Show More]

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