Hurst NCLEX Test Taking Strategy Questions With Rationale / latest 2022

NCLEX Test Taking Strategy Questions 1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the client’s urine output suddenly increases significantly. Which actio ...

NCLEX Test Taking Strategy Questions 1. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the client’s urine output suddenly increases significantly. Which action takes highest priority? o 1. Monitoring urine output o 2. Checking pulse o 3. Checking blood pressure o 4. Assessing level of consciousness Rationale: 3. Correct: This is the best answer because we are “worried” this client is going into SHOCK. So…..you better be checking a BP. This is a time where checking the BP is appropriate. If we “assume the worst” I better check a blood pressure. It could have dropped out the bottom. 1. Incorrect: Continuing to monitor U/O is important but I need to find out if they are already shocky. 2. Incorrect: Checking the pulse is a good thing, but, not as important as checking the BP. 4. Incorrect: If my client is going into shock the highest priority is to assess the BP. 2. The client is being treated for fluid volume deficit. Which is an expected outcome of successful treatment? o 1. Resolution of orthostatic hypotension o 2. Maintenance of weight loss o 3. Compliance with sodium restricted diet o 4. Maintenance of serum Na above 148 mEq Rationale: 1. Correct: When you are in a fluid volume deficit your blood pressure goes down when you stand up and it’s called orthostatic hypotension. Successful treatment would resolve this. 2. Incorrect: When I have lost a lot of volume, my weight goes down, so if I am better, my weight should go up. 3. Incorrect: Who needs to adhere to dietary sodium restrictions? People who are in fluid volume excess. 4. Incorrect: If your serum sodium is above 148, hypernatremia is the same thing as dehydration, so this means that you are still sick. 3. The nurse in the intensive care unit is caring for a client receiving hemodynamic monitoring. When planning for a client’s care, which nursing diagnoses associated with hemodynamic monitoring may be utilized by the nurse? Select all that apply. F 1. Decreased cardiac output F 2. Fluid volume deficit F 3. Fluid volume excess F 4. Ineffective tissue perfusion F 5. Ineffective airway Rationale: 1., 2., 3. & 4. Correct: Nursing diagnoses, associated with hemodynamic monitoring, that may be utilized by the nurse include decreased cardiac output, fluid volume deficit, fluid volume excess, and ineffective tissue perfusion. These nursing diagnoses relate to the pathophysiologic processes that alter one of the four hemodynamic mechanisms that support normal cardiovascular function: preload, afterload, heart rate, and contractility. 5. Incorrect: Ineffective Airway would not be associated with hemodynamic monitoring. 4. The nurse is caring for a client that has two IV access sites. One is a 20 gauge antecubital peripheral IV that was started yesterday for blood and has normal saline (NS) at keep vein open rate. The other is a double lumen central line catheter with one port for Total Parental Nutrition and the other is used for blood samples. Where is the best site for the nurse to administer 20 mEq of potassium chloride (KCL) in 100 mL of normal saline(NS) over 4 hours? o 1. Central line port that is being used for lab draws o 2. Same line with the Total Parental Nutrition o 3. Large bore antecubital o 4. Start another peripheral IV Rationale: 1. Correct: Yes- K is very hard on the veins, give it through the central line. 2. Incorrect: No, never put anything through a line with Total Parental Nutrition. 3. Incorrect: Second best choice- but it will burn. 4. Incorrect: No, a central line is needed. 5. The nurse is caring for a client that has metabolic acidosis secondary to acute renal failure. What is the initial client response to this problem? o 1. Respiratory rate increases to blow off acid. o 2. Respiratory rate decreases to conserve acid and buffer the kidneys response. o 3. Kidneys will excrete hydrogen and retain bicarb. o 4. Sodium will shift to cells and buffer the hydrogens. Rationale: 1. Correct: Yes, acute renal failure causes metabolic acidosis and the body is trying to breathe faster to blow off some acid. The respiratory response is fast. 2. Incorrect: No, the client’s respiratory rate is fast, not slow. 3. Incorrect: This will happen, later. Did not we say about 48 hours? Not initial response. 4. Incorrect: Sodium is extracellular electrolyte, not an intracellular electrolyte. 6. The client presents to the emergency department with nausea, vomiting and anorexia for the last few days. An EKG on admission reveals an arrhythmia. Which electrolytes imbalance is suspected? o 1. Hypercalcemia o 2. Hypokalemia o 3. Hypermagnesemia o 4. Hyponatremia Rationale: 2. Correct: The client has been vomiting so the electrolytes losses are potassium, hydrogen and chloride. The anorexia further complicates the condition because we get potassium from the foods we eat. The one electrolyte we worry about with arrhythmias is potassium. 1. Incorrect: What has calcium got to do with nausea and vomiting? Nothing 3. Incorrect: Magnesium is loss through the lower GI tract and Hypermagnesemia is not related to dysrhythmias. 4. Incorrect: The loss of sodium is related to diarrhea. 7. The nurse is caring for a client that is drowsy and has an elevated CO2. What are some common drugs that cause retained CO2? Select all that apply F 1. Narcotics F 2. Diuretics F 3. Steroids F 4. Antiemetics F 5. Hypnotics Rationale: 1., 4. & 5. Correct: Yes! – Narcotics sedate and decrease the respiratory rate. Some antiemetics like promethazine (Phenergan) are very sedating. Hypnotics can cause sedation to point of hypoventilation. 2. Incorrect: No – Diuretics do not affect breathing patterns. 3. Incorrect: No –Steroids do not affect breathing patterns 8. A client was admitted 24 hours ago with sepsis. Treatment included IV therapy of lactated Ringers (LR) at 150 ml/hr, broad spectrum antibiotics, and steroid therapy. How will the nurse know that treatment has been successful? Select all that apply. F 1. Blood pressure 96/68; HR- 98; RR- 20 F 2. Serum Glucose- 110 F 3. Hgb- 12; Hct- 38 F 4. pH- 7.30; pCO2- 48; HCO3- 24 F 5. Urinary output at 25 ml/hr F 6. Awake, alert to person, place and time Rationale: 1., 2., 3. & 6. Correct: The systolic BP should be greater than 90. The other lab work is normal as well. 4. Incorrect: The client is still in respiratory acidosis, so is not better. 5. Incorrect: Urinary output should be at least 30 ml/hr. 9. The daytime charge nurse identifies that a client was treated for what condition during the night after reading the following chart entries?