Download Carena Jarding Dakota Wesleyan University 1.) The client

Carena Jarding
Dakota Wesleyan University
1.)
a.
b.
c.
d.
2.)
a.
b.
c.
d.
e.
3.)
a.
b.
c.
d.
e.
The client diagnosed with a panic attach disorder in the busy day room of a psychiatric unit becomes anxious, starts
to hyperventilate and tremble, and is diaphoretic. Which intervention should the nurse implement first?
Administer the benzodizephoine alprazolam (Xanax)
Discuss what caused the client to have a panic attack
Escort the client from the day room to a quiet area
Instruct unlicensed assistive personnel to take the client’s vital signs
Answer C: The first intervention is to remove the client from the busy day room to a quiet area to help decrease the
anxiety attack. Providing medication for an anxiety attack is important, but it will take at least 15-30 min for the
medication to treat the physiologic signs/symptoms. Therefore, this is not the first intervention. The nurse should
discuss the panic attack and what prompted it, but it is not the nurse’s first action. The client’s vital signs should be
taken, but this is not the nurse’s first intervention.
The client diagnosed with a brain tumor is ordered the osmotic diuretic mannitol (Osmitrol) to be given
intravenously. Which interventions for this medication should the nurse implement? Select all that apply.
Inspect the bottle for crystals
Record intake and output every 8 hours
Auscultate the client’s lung fields
Perform a neurological examination
Have a calcium gluconate at the bedside
Answer A, B, C: Mannitol can crystallize in the containers in which it is packaged, and the crystals must not be
infused into the client. The nurse should inspect the bottle for crystals before beginning the administration. Any client
receiving a diuretic should be monitored for intake and output to determine if the client is excreting more than the
intake. Mannitol is an osmotic diuretic and works by pulling fluid from the tissues into the blood vessels. Clients
diagnosed with heart failure may develop fluid volume overload. Therefore, the nurse should assess lung sounds
before administering this medication. The nurse does not have to perform a neurological exam for this
medication. The nurse should do this for the disease diagnosis. Calcium gluconate will not affect this medication,
nor is it an antidote.
The client on the medical unit is exhibiting peaked T waves on the electrocardiogram. Which interventions should
the nurse implement? List in order of priority.
Assess the client for leg and muscle cramps
Check the serum potassium level
Notify the health-care provider
Arrange for a transfer to the telemetry floor
Administer Kayexalate, a cation resin
Answer: A, B, C, E, D – The nurse should assess to determine if the client is symptomatic of hyperkalemia. A
peaked T wave is indicative of hyperkalemia, therefore, the nurse should obtain a potassium level. Hyperkalemia is a
life-threatening situation because of the risk of cardiac dysrhythmia, therefore, the nurse should notify the health-care
provider. Kayexalate is a medication that will help remove potassium through the gastrointestinal system and should
be administered to decrease the potassium level. The client should be monitored continuously for cardiac
dysrhythmias so a transfer to the telemetry unit is warranted.
Helene Hegge
USD
NCLEX Questions
1.
Which of the following should be included in the care plan for a client admitted with acute renal
colic?
A. Inserting an indwelling urinary catheter
B. Straining all urine
C. Maintaining T-tube patency
D. Limiting fluid intake to 1 to 2 liters/day.
Correct answer: B
RATIONALE: The urine of a client with renal colic should be strained through gauze to
assess for the presence of calculi. Invasive catheterization isn’t done because it increases
the risk of infection. A T-Tube is used to drain bile from the biliary tract. Fluids are
increased for a client with renal colic; 3-4 liters/day are recommended to facilitate
passage of calculi.
2.
A client with exacerbation of chronic obstructive pulmonary disease (COPD) and pneumonia has
the following arterial blood gas (ABG) results: pH, 7.30; partial pressure of arterial carbon
dioxide, 60 mmHg; partial pressure of arterial oxygen, 75 mmHg; and bicarbonate, 24 mEq/L.
The nurse anticipates which intervention?
A. Increase oxygen via face mask.
B. Encourage coughing and deep breathing.
C. Administer sodium bicarbonate.
D. No intervention is needed; ABG values are normal.
Correct answer: B
RATIONALE: These ABG results indicate respiratory acidosis. Ventilation may be
impaired by mucus and inflammation. Therefore, the client who’s alert should perform
proper coughing. If the client can’t cough and deep breathe, suctioning may be required.
Increasing oxygen in a client with COPD may cause hypoventilation by removing the
hypoxic drive. Sodium bicarbonate would be administered for a client with metabolic
acidosis. In this case, the elevated carbon dioxide is producing the acidosis.
3. A toddler is admitted with a seizure disorder. According to the parents, the client stops
breathing and turns blue after having a seizure. The physician prescribes phenytoin (Dilantin).
Before discharge, the nurse teaches the parents how to handle seizures. Which instruction
should the nurse include?
A. Give the client the medication as soon as a seizure begins.
B. Place a tongue blade in the client’s mouth during a seizure.
C. Remove nearby objects that could cause injury during a seizure.
D. Keep the medication in the client’s room so that it won’t be forgotten.
Correct Answer: C
Rationale: The nurse should be sure to teach parents how to prevent injury during a
seizure. The nurse should explain that placing something in the mouth—even medication
or a tongue blade—increases the risk of airway obstruction. Also, the nurse should
advise the parents to keep all medications out of the reach of children.
4. The nurse is assessing a geriatric client with senile dementia. Which neurotransmitter condition
is most likely to contribute to the client’s cognitive changes?
A. Decreased acetylcholine level
B. Increased acetylcholine level
C. Increased norepinephrine level
D. Decreased norepinephrine level
Correct Answer: B
Rationale: A decreased acetylcholine level has been implicated as a cause of cognitive
changes in healthy geriatric clients and has been implicated as a cause of cognitive
changes in healthy geriatric clients and in the severity of dementia. Choline
acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be
deficient in clients with dementia. Norepinephrine is associated with aggression, sleepwake patterns, and the regulation of physical responses to emotional stimuli, such as the
increased heart and respiratory rates caused by panic.
Kim Mohr
Dakota Weslyan University
1. A nurse’s laboring client is experiencing decelerations that occur after the onset of the contraction
and do not end until after the contraction is completed. The fetal heart rate variability is minimal.
Which interventions should the nurse initiate? Select all that apply:
a. Increase intravenous fluids
b. Administer oxygen via facemask
c. Increase the Pitocin
d. Turn the client to her left side
e. Reassess in 30 minutes
Rationale:
The question is describing a late deceleration. Interventions for this condition include: a. b. d. Answer C.
would not be correct ,as increasing the Pitocin could make late decels worse, and answer E. is not
correct because the nurse needs to reassess continually, not in 30 mins.
2. The nurse has just received morning change-of-shift report on four clients assigned to this shift. In
what order should the nurse do the following?
1. Discuss the plan for the day with the nursing assistant, delegating duties as appropriate
2.
Assess the client who has been vomiting according to report from the night nurse
3.
Begin discharge paperwork for a client that is anxious to go home
4.
Notify the physician about a client who’s potassium level has just been reported as 6.2
Correct Answer: 4, 2, 1, 3
The nurse should first notify the physician of the high potassium level. Normal serum potassium level is
3.5 to 5.0. Serious cardiac arrhythmias, potentially life threatening could result if left untreated. The
nurse should next assess the client who has been vomiting and if necessary contact the physician for a
prescription for an antiemetic if none has been prescribed. After assessing all clients, the nurse should
discuss the plan for the day with the NA, delegating as appropriate. Though the client is eager to go
home, the discharge paperwork must wait until all clients have been assessed and immediate needs
met.
Cheri Kovalenko
University of Sioux Falls
A patient with decreased cardiac contractility is in the emergency room. The provider is
considering a bolus of IV fluids. What would be the concern with this, given your knowledge of
the Frank Starling principle?
Initially, extra fluids may produce improved cardiac contractility. However, if too much fluid is given,
cardiac output will decrease.
B. There is no concern. Extra fluid will always help this patient.
C. Cardiac output might decrease right away, but there will always be better contractility with additional
fluids.
D. None of the above.
Answer: A.
A.
The Frank Starling principle says that in this situation, an increase in volume will lead to an increase in
contractility, but only to a point. When the muscle fibers are stretched beyond the point of ideal
overlap, contractility will decrease, and hence, cardiac output will likely decrease as well. Therefore, a
gentle fluid bolus could help, but clinicians must be astute to the fact that too much fluid would likely be
harmful in this situation.
What are the effects of the sympathetic nervous system on the cardiovascular system? CHOOSE
ALL THAT APPLY.
A.
B.
C.
D.
E.
GI stimulation.
Increased heart rate.
Vasoconstriction.
Mobilization of blood stored in venous side of circulation.
Smooth muscle relaxation.
Answer: B, C, D
The SNS is a powerful compensatory mechanism to maintain cardiac output. Increased HR will help
offset a decrease in volume to maintain cardiac output. Vasoconstriction in the periphery serves to
shunt blood to most critical organs and raise blood pressure, as well as mobilizing blood that has been
stored in the venous side of circulation. The SNS shunts blood away from the GI system and does not
stimulate it. It causes smooth muscle constriction in the cardiovascular system.