NCLEX - Physiological Adaptation Day1 (Part 1)

The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum

• Calcium level
• Albumin level
• Troponin T level
• Potassium level

Answer explanation

Option 1: Calcium level

Option 2: Albumin level

Option 3: Troponin T level

Option 4: Potassium level

Correct Option: Option 1

Explanation: Carpal spasm is a classic sign of hypocalcemia, often seen in acute pancreatitis. It’s associated with Trousseau’s sign, and requires checking the serum calcium level urgently.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?

• My pain is a burning sensation in my upper abdomen.
• My pain is an 8 out of 10 and on my left side below my belly button.
• My pain is excruciating in my lower abdomen above my right hip.
• My pain is intermittent in my abdomen and right shoulder.

Answer explanation

Option 1: My pain is a burning sensation in my upper abdomen.

Option 2: My pain is an 8 out of 10 and on my left side below my belly button.

Option 3: My pain is excruciating in my lower abdomen above my right hip.

Option 4: My pain is intermittent in my abdomen and right shoulder.

Correct Option: Option 3

Explanation: Appendicitis pain typically starts around the umbilicus and shifts to McBurney’s point—the right lower quadrant, above the right hip.

The nurse is caring for a client with a hemothorax who has a chest tube attached to a closed-chest drainage system. The nurse notes a sudden decrease in drainage from the chest tube over the past 2 hours. Which of the following actions should the nurse take?

• Reposition the client.
• Auscultate the client's breath sounds.
• Replace the closed-chest drainage system.
• Prepare the client for removal of the chest tube.
• Instruct the client to cough and take deep breaths.

Answer explanation

Option 1: Reposition the client.

Option 2: Auscultate the client's breath sounds.

Option 3: Replace the closed-chest drainage system.

Option 4: Prepare the client for removal of the chest tube.

Option 5: Instruct the client to cough and take deep breaths.

Correct Option: 1, 2, 5

Explanation: A sudden decrease in drainage could be positional or obstruction-related. Repositioning, breath sounds, and cough/deep breathing help restore effective drainage.

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?

• Acetaminophen PO PRN for fever
• Clindamycin IV every 8 hours
• Lactated Ringer IV bolus once
• Methylergonovine PO every 4 hours

Answer explanation

Option 1: Acetaminophen PO PRN for fever

Option 2: Clindamycin IV every 8 hours

Option 3: Lactated Ringer IV bolus once

Option 4: Methylergonovine PO every 4 hours

Correct Option: Option 2

Explanation: Clindamycin treats the root cause—polymicrobial infection. Antibiotics are priority in endometritis to prevent serious complications.

The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown. The nurse should recognize that the client is experiencing

• Atrial flutter
• Ventricular tachycardia
• Premature atrial contractions
• Premature ventricular contractions

Answer explanation

Option 1: Atrial flutter

Option 2: Ventricular tachycardia

Option 3: Premature atrial contractions

Option 4: Premature ventricular contractions

Correct Option: Option 4

Explanation: Wide, distorted QRS complexes are typical of premature ventricular contractions (PVCs).

The nurse is caring for a client with primary hyperparathyroidism. Which of the following findings would be consistent with the condition?

• Seizures
• Diarrhea
• Muscle weakness
• Perioral numbness

Answer explanation

Option 1: Seizures

Option 2: Diarrhea

Option 3: Muscle weakness

Option 4: Perioral numbness

Correct Option: Option 3

Explanation: Hyperparathyroidism causes hypercalcemia, and muscle weakness is a hallmark symptom.

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm?

• Biting endotracheal tube
• Disconnected ventilator tubing
• Endotracheal tube cuff leak
• Excessive airway secretions
• Kinked ventilator tubing

Answer explanation

Option 1: Biting endotracheal tube

Option 2: Disconnected ventilator tubing

Option 3: Endotracheal tube cuff leak

Option 4: Excessive airway secretions

Option 5: Kinked ventilator tubing

Correct Option: 1, 4, 5

Explanation: High-pressure alarms are triggered by obstruction or resistance like biting the tube, secretions, or kinked tubing.

The nurse is teaching an adolescent client who has developed external otitis for the third time this year. Which of the following information should the nurse include?

• Consider wearing custom-fit earplugs for swimming.
• Avoid getting water in your ears until they have healed.
• Tilt your head from side to side after swimming to help dry your ears.
• Apply a warm compress to the outside of your ear to help reduce discomfort.
• Keep your ear canals free of wax by cleaning them with cotton-tipped applicators.

Answer explanation

Option 1: Consider wearing custom-fit earplugs for swimming.

Option 2: Avoid getting water in your ears until they have healed.

Option 3: Tilt your head from side to side after swimming to help dry your ears.

Option 4: Apply a warm compress to the outside of your ear to help reduce discomfort.

Option 5: Keep your ear canals free of wax by cleaning them with cotton-tipped applicators.

Correct Option: Options 1, 2, 3, 4

Explanation: Drying and protecting the ear from moisture promotes healing. Avoiding cotton-tipped applicators prevents trauma.

The nurse is caring for a client recently diagnosed with a hiatal hernia. Which of the following actions should the nurse take?

• Elevate the head of the bed at least 30 degrees
• Encourage use of compression garments around the abdomen
• Instruct the client to avoid caffeinated beverages
• Offer small, frequent, low-fat meals
• Tell the client to avoid lifting and straining

Answer explanation

Option 1: Elevate the head of the bed at least 30 degrees

Option 2: Encourage use of compression garments around the abdomen

Option 3: Instruct the client to avoid caffeinated beverages

Option 4: Offer small, frequent, low-fat meals

Option 5: Tell the client to avoid lifting and straining

Correct Option: Options 1, 3, 4, 5

Explanation: Managing GERD symptoms with positioning, diet changes, and avoiding strain is key for hiatal hernia care.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation?

• Maintain the head of the bed at 30-45 degrees
• Mute ventilator alarms at night to allow the client to rest
• Pause sedation daily to assess weaning readiness
• Perform oral care with chlorhexidine solution
• Place a manual resuscitation bag at the bedside

Answer explanation

Option 1: Maintain the head of the bed at 30-45 degrees

Option 2: Mute ventilator alarms at night to allow the client to rest

Option 3: Pause sedation daily to assess weaning readiness

Option 4: Perform oral care with chlorhexidine solution

Option 5: Place a manual resuscitation bag at the bedside

Correct Option: Options 1, 3, 4, 5

Explanation: Alarms must stay active. Sedation breaks and hygiene reduce risks like VAP; emergency equipment ensures preparedness.