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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q176-Q181):
NEW QUESTION # 176
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
- A. Collapsed neck veins
- B. Decreased anteroposterior chest diameter
- C. Distant breath sounds
- D. Increased heart sounds
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.
NEW QUESTION # 177
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
Answer: B
Explanation:
Explanation
(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
NEW QUESTION # 178
Before completing a nursing diagnosis, the nurse must first:
- A. Perform evaluation
- B. Write goals and objectives
- C. Plan interventions
- D. Perform an assessment
Answer: D
Explanation:
(A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.
NEW QUESTION # 179
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
- A. Assists with ambulation
- B. Decreases hypertrophic scar formation
- C. Covers burn scars and decreases the psychological impact during recovery
- D. Increases venous return and cardiac output by normalizing fluid status
Answer: B
Explanation:
Explanation
(A) Tubular support, such as that received with a Jobst garment, applies tension of 10-20 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 6-12 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status.
NEW QUESTION # 180
The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is:
- A. Hypertensive crisis
- B. Oculogyric crisis
- C. Orthostatic hypotension
- D. Tardive dyskinesia
Answer: A
Explanation:
(A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.
NEW QUESTION # 181
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