NCLEX PRACTICE

While assessing a one-month old infant, which of the findings warrants further investigation by the nurse? Select all that apply.

• Abdominal respirations

• Cyanosis

• Increased heart rate with crying

• Asymmetric chest movement

• Nasal flaring

Answer explanation

Abdominal respirations is normal among infants since their intercostal muscles are not fully developed

Cyanosis refers to bluish discoloration of the skin and indicates decrease in O2

Increased heart rate is normal and fluctuations in heart rate follow changes in behavior such as crying, wakefulness and movement

Asymmetric chest movement occurs when abnormal side of the lungs expands less and lags behind the normal side indicating respiratory distress

Nasal flaring occurs when nostrils widen while breathing and is a sign of troubled breathing or respiratory distress

Which individual is at the greatest risk for developing hypertension?

• 45-year-old African America attorney

• 60-year-old Asian American shop owner

• 40-year-old Caucasian nurse

• 55-year-old Hispanic teacher

Answer explanation

African-Americans develop high blood pressure at younger ages than other groups in the US. Researchers have uncovered that African-Americans respond differently to hypertensive drugs than other groups of people. They are also found out to be more sensitive to salt, which increases the risk of developing hypertension.

15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?

• Gastric Lavage

• Administer acetylcysteine (Mucomyst) orally

• Start IV D5 with 0.33% normal saline to keep vein open

• Have patient drink activated charcoal mixed with water

Answer explanation

Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion.

Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of acetaminophen overdose but should be done after GI decontamination.

Option C: Intermittent IV infusion with Dextrose 5% may be considered for late-presenting or chronic ingestion.

Option D: Charcoal should not be administered immediately before or with antidotes since it can effectively adsorb it and neutralize the benefits.

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

• Angina at rest

• Thrombus formation

• Dizziness

• Falling blood pressure

Answer explanation

Correct Answer: B. Thrombus formation

A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body.

Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular-related diseases and technique-related factors.

Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

• Maintain fluid and electrolyte balance

• Control nausea

• Manage pain

• Prevent UTI

Answer explanation

C. Manage pain

Managing pain is always a priority because it ultimately improves the quality of life.

Option A: IV hydration in the setting of acute renal colic is controversial. Whereas some authorities believe that IV fluids hasten the passage of the stone through the urogenital system, others express concern that additional hydrostatic pressure exacerbates the pain of renal colic.

Option B: Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating effect that is often helpful.

Option D: Overuse of the more effective antibiotic agents leaves only highly resistant bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can result in potentially life-threatening urosepsis and pyonephrosis.

What would the nurse expect to see while assessing the growth of children during their school-age years?

• Decreasing amounts of body fat and muscle mass

• Little change in body appearance from year to year

• Progressive height increase of 4 inches per year

• Yearly weight gain of about 5.5lbs per year

Answer explanation

D. Yearly weight gain of about 5.5 pounds per year

School-age children gain about 5.5 pounds each year and increase about 2 inches in height. Between ages 2 to 10 years, a child will grow at a steady pace.

Option A: Decreasing amounts of body fat and muscle mass are common in toddlers.

Option B: A decrease in the change in body appearance occurs among young adults.

Option C: Growth spurts are common in school-age children, as are periods of slow growth.

At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to:

• Go get a BP check within the next 15 minutes

• Check BP again in 2 months

• See healthcare provider immediately

• Visit healthcare provider within 1 week for a BP check

Answer explanation

A. Go get a blood pressure check within the next 15 minutes. The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke.

Options B & D: Waiting 2 months or a week for follow-up is too long.

Option C: Immediate check by the provider of care is not warranted.

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?

• Middle-aged client w/ history of being ventilator dependent for over 7 years and admitted with bacterial PNA 5 days ago

• Young adult with DM2 for over 10 years and admitted with antibiotic-induced diarrhea 24 hours ago

• Elderly client with history of HTN, hypercholesterolemia, and lupus, and was admitted with SJS that morning

• Adolescent with positive HIV test and admitted for acute cellulitis of lower leg 48 hours ago.

Answer explanation

A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

Option B: The client with antibiotic-induced diarrhea still needs continuous strict monitoring as the blood sugar levels may become unstable and dehydration is still possible.

Option C: Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters.

Option D: Cellulitis is often an underestimated complication of HIV disease, but they are responsible for an appreciable morbidity.

A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

• Should be taken in the morning

• May decrease the client's energy level

• Must be store in a dark container

• Will decrease the client's heart rate

Answer explanation

Option A: Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client’s sleeping pattern.

Option B: Some of the side effects of Levothyroxine include hyperactivity and an increase in heart rate.

Option C: Keep this drug in a cool, dark, and dry place.

Option D: A decrease in the heart rate is the desired effect of Levothyroxine.

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

• Prepare the child for x-ray of upper airways

• Examine the child's throat

• Collect a sputum specimen

• Notify the healthcare provider of the child's status

Answer explanation

D. Notify the healthcare provider of the child’s status

These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.

Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis.

Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort.

Option C: There are no indications for the collection of sputum specimens.