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NCLEX-RN Exam Questions - Part 118
1. A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
A) Assess the site for leakage of blood or fluids
B) Auscultate the site for a bruit
C) Assess the site for bruising or hematoma
D) Inspect the site for color, warmth, and sensation
2. A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A) Warmed solution helps keep the body temperature maintained within a normal range during instillation
B) Warmed solution helps dilate the peritoneal blood vessels
C) Warmed solution decreases the risk of peritoneal infection
D) Warmed solution promotes a relaxed abdominal muscle
3. A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A) Crackles or rales on the affected side
B) Bradypnea and bradycardia
C) Shortness of breath and sharp pain on the affected side
D) Increased breath sounds on the affected side
4. A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A) Instruct the client to cough deeply to re-expand her lung
B) Put on sterile gloves and replace the tube
C) Apply a petrolatum dressing over the site
D) Auscultate the lung to determine if she needs the tube replaced
5. A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
A) Pain in his legs when he walks
B) Thirst, weight loss, and polyuria
C) Drowsiness and lethargy after his activities
D) Weight gain, edema in his lower extremities, and shortness of breath
A) Assess the site for leakage of blood or fluids
B) Auscultate the site for a bruit
C) Assess the site for bruising or hematoma
D) Inspect the site for color, warmth, and sensation
2. A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
A) Warmed solution helps keep the body temperature maintained within a normal range during instillation
B) Warmed solution helps dilate the peritoneal blood vessels
C) Warmed solution decreases the risk of peritoneal infection
D) Warmed solution promotes a relaxed abdominal muscle
3. A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
A) Crackles or rales on the affected side
B) Bradypnea and bradycardia
C) Shortness of breath and sharp pain on the affected side
D) Increased breath sounds on the affected side
4. A female client has a chest tube placed. It is accidentally pulled out of the intrapleural space when she is ambulating. The first action the nurse should take is to:
A) Instruct the client to cough deeply to re-expand her lung
B) Put on sterile gloves and replace the tube
C) Apply a petrolatum dressing over the site
D) Auscultate the lung to determine if she needs the tube replaced
5. A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
A) Pain in his legs when he walks
B) Thirst, weight loss, and polyuria
C) Drowsiness and lethargy after his activities
D) Weight gain, edema in his lower extremities, and shortness of breath
1. Right Answer: B
Explanation: (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
2. Right Answer: B
Explanation: (A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D)Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
3. Right Answer: C
Explanation: (A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
4. Right Answer: C
Explanation: (A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.
5. Right Answer: D
Explanation: (A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The clients activity level should be evaluated.
Explanation: (A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
2. Right Answer: B
Explanation: (A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D)Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
3. Right Answer: C
Explanation: (A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
4. Right Answer: C
Explanation: (A) This action is inappropriate. Coughing will not re-expand the lung and could result in further harm. (B) This action is a medical procedure, not a nursing procedure. (C) An occlusive dressing will prevent further air leak until the physician institutes further treatment. (D) The decision to reinsert the tube is a medical decision, not a nursing one.
5. Right Answer: D
Explanation: (A) Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. (B) Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. (C) Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. (D) All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The clients activity level should be evaluated.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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