NCLEX-RN Practice Exam 6
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. Options A, C, and D: If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance.
The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?
During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Options A, B, and C do not indicate that the ECT has been effective.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?
The vital signs are abnormal and should be reported immediately. Option A: Continuing to monitor the vital signs can result in deterioration of the client’s condition. Option C: Asking the client how he feels will only provide subjective data. Option D: Assigning an unstable client to an LPN is inappropriate.
The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?
Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.
The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?
It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant Staphylococcus aureus, gloves should be worn. Options A, B, and C: The health care workers indicate knowledge of infection control by their actions.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Option A: does not apply for a child who has undergone a tonsillectomy. Options B and D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority.
The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:
The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Option A: Repositioning the monitor is not indicated at this time. Option C: Asking the client to ambulate is not the best action for clients experiencing bradycardia. Option D: There is no data to indicate the need to move the client to the delivery room at this time.
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Options A and B: Allowing the child to have items that are familiar to him is allowed and encouraged. Option D: Telling the child that screaming is inappropriate behavior is not part of the nurse’s responsibilities.
Which of the following is a characteristic of a reassuring fetal heart rate pattern?
Accelerations with movement are normal. Options A, B, and C: These assessments indicate ominous findings on the fetal heart monitor.
George Kent is a 54 year old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty in communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?
The patient has respiratory acidosis (raised carbon dioxide) resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation.
Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?
The student was diagnosed having diabetes mellitus. The results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2).
A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean?
The primary disorder is acute respiratory alkalosis (low CO2) due to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation.
Ricky’s grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?
The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.
Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean?
The results show that Mrs. Johansson has respiratory acidosis because of decreased pH and increased PaCO2 which mean acidic in nature. Meanwhile, it is uncompensated because HCO3 is within the normal range.
Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean?
Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.
Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment?
The postoperative client’s ABG results show that he has metabolic alkalosis because of an increased pH and HCO3. It is uncompensated due to the normal PaCO2 which is within 35 to 45 mmHg.