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Thursday, December 4, 2008

2008 Free Nclex Sample Questions Rationalized

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Signs of postoperative hemorrhage include pallor, restlessness, frequent swallowing, large amounts of bloody drainage or vomitus, increasing pulse rate, and a falling blood pressure. These signs should be reported to the surgeon. While restlessness and an increased pulse could result from the presence of pain, those signs along with the others identified in the question indicate postoperative bleeding. These signs are not expected postoperative findings and are not related to the presence of edema.

The client with pneumonia may experience decreased taste sensation as a result of sputum expectoration. To minimize this adverse effect, the nurse should provide oral hygiene before meals. The client should also have small, frequent meals because of dyspnea. Increased oral fluids and keeping water at the bedside are good measures to prevent fluid deficit associated with pneumonia, but they do nothing to alleviate anorexia.

mmunizations against influenza are a prophylactic measure and are not used to treat flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. Medications such as antipyretics and analgesics may also be used for symptom management.

General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mm Hg.

PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

Headache is a common side effect of nitroglycerin because of its vasodilator properties. The incidence of headache diminishes over time as the client develops tolerance to the medication. The client should be encouraged to continue its use as needed and to take acetaminophen (Tylenol) or aspirin for headache, according to the preference of the prescribing physician.

The client with pulmonary edema presents primarily with symptoms that are respiratory in nature, because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure.

When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the bolus with infusions of normal saline.

The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the nurse pulls down and back on the ear lobe. The wrist of the dominant hand is rested on the infant’s head. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal.

Hoarseness is a common early sign of laryngeal cancer, but not of bronchogenic or thyroid cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.

Chest tube drainage should not exceed 100 mL per hour during the first 2 hours postoperatively, and approximately 500 mL of drainage is expected in the first 24 hours after cardiac surgery. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further assessment by the nurse.

Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears.

A typical symptom of pleurisy is knife-like pain that worsens on inspiration caused by the friction created by rubbing together inflamed pleural surfaces. This pain usually disappears when the breath is held, because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat.

Tambocor (Flecainide) is an antidysrhythmic medication that slows conduction and decreases excitability, conduction velocity, and automaticity. The nurse needs to monitor for the development of a new or a worsening dysrhythmia.

Brown-Séquard’s syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation is lost because these fibers decussate after entering the cord.

All of these assessments would be performed on a client with a suspected spinal cord injury. However, respiratory status is the priority.

The most likely medication to be prescribed for a client with a newly diagnosed spinal cord injury is dexamethasone (Decadron). This medication is a short-acting glucocorticoid and would be administered to reduce traumatic edema. The use of propranolol (a beta-blocker), furosemide (a diuretic), or morphine sulfate (an opioid analgesic) would not be indicated based on the information

Clients with AIDS frequently develop opportunistic infections. Candida albicans, the causative organism of thrush, is a common opportunistic infection. Thrush presents as white patches in the oral cavity.

Shortness of breath and tracheal deviation results when lung tissue and alveoli have collapsed. The trachea deviates to the unaffected side in the presence of a tension pneumothorax. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from a decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal shift and impedance of venous return to the heart. However, it may also be the result of other problems such as a failing heart.

In newborn males, prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. It is best to allow separation to occur naturally, which will happen between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

With an immediate-release preparation, the oral aminophylline should be administered in 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose should be administered immediately upon discontinuation of the IV infusion.

The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, toe, or ear lobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is saturated with oxygen (Sao2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client’s finger. If values fall below preset norms (usually 90%), the client should be instructed to deep breathe, if this is appropriate. It is not necessary to call the physician immediately unless measures such as deep breathing do not raise the level back to normal.

Interventions are directed at preventing the progression of thromboangiitis obliterans and include conveying the need for immediate smoking cessation, providing medications prescribed for vasodilation, such as nifedipine (Procardia) a calcium channel blocker, or prazosin (Minipress) an alpha-adrenergic blocker. The client should maintain warmth to the extremities, especially by avoiding exposure to cold. The client should inspect the extremities and report signs of infection or ulceration.

A social phobia is characterized by a fear of appearing incompetent or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious when the attention is on them.

Urinary retention is a side effect of benztropine mesylate (Cogentin). The nurse needs to monitor the client’s intake and output and observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence.

Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output.

Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease. Severe cardiac disease can be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occurs with hemodialysis. For the same reason, peritoneal dialysis may be indicated for the client with diabetes mellitus. Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticuli or malignancies; extensive abdominal surgeries; history of peritonitis; obesity; and those with a history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system may also be a contraindication.

Crackles in the lung fields of the peritoneal dialysis client result from overhydration or from insufficient fluid removal during dialysis. An intake that is greater than the output of peritoneal dialysis fluid would overhydrate the client, resulting in lung crackles.

A peak expiratory flow rate meter is used to provide an objective measure of the client’s peak expiratory flow. The client is instructed to take the deepest possible breath, form a tight seal around the mouthpiece with the lips, and exhale forcefully and rapidly. The final position of the indicator on the meter is recorded.

There are key advantages to the use of a spacer device for medications administered by inhalation. One is that it reduces the incidence of yeast infections, because large medication droplets are not deposited on oral tissues. The medication is also dispersed more deeply and uniformly than without a spacer. There is less need to coordinate the effort of inhalation with pressing on the canister of the inhaler. Finally, the use of a spacer may decrease either the number or the volume of the puffs taken.

Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after the onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by early onset of cough (before dyspnea), copious purulent sputum production, minimal weight loss, and milder severity of dyspnea.

With late-stage emphysema, the retention of carbon dioxide can lead to carbon dioxide narcosis. This is manifested by occipital headache, drowsiness, inability to concentrate, confusion, and tremors. Other signs are a bounding pulse and an arterial carbon dioxide level greater than 75 mm Hg.

If flail chest is present, the nurse applies firm yet gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the client’s respiratory status. The nurse does not move an injured person because of the risk of worsening an undetected spinal cord injury.

The pain of angina may radiate to the left arm, is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, is frequently accompanied by associated symptoms (nausea, vomiting, dyspnea, diaphoresis, anxiety), and requires opioid analgesics for relief. A burning and gnawing pain is more likely noted in a upper gastrointestinal disorder.

Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure (BP), accompanied by paradoxical pulse (a drop in inspiratory BP by greater than 10 mm Hg).

The client undergoing pericardiocentesis is positioned supine with the head of the bed raised to a 30- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac.

The therapeutic phenytoin (Dilantin) level is 10 to 20 mcg/mL. Blood levels above 30 mcg/mL produce slurred speech.

The child with cleft palate repair is placed on the right side after feeding to reduce the chance of aspirating regurgitated formula.

Nausea and vomiting should not occur if the NG tube is patent. The NG tube should not be repositioned or irrigated after gastric surgery because it is placed directly over the suture line. The NG tube is irrigated gently with normal saline only with a physician’s order. The client may need medication for the nausea, but in this situation, the physician should be notified.

The long-term prognosis for newborns with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal distention, hyperactivity, abnormal reflexes, and uncontrollable crying. Central nervous system (CNS) disorders are the most common problems associated with FAS. Because of the CNS disorders, children born with FAS are often hyperactive and have a high incidence of speech and language disorders. Symptoms of withdrawal often occur within 6 to 12 hours after life or at the latest, within the first 3 days of life. Most neonates with FAS are mildly to severely mentally retarded. The newborn is usually growth deficient at birth.

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