This nclex nursing exam is related to fundamentals of nursing subject to the concept of nursing interventions and proper techniques from assessment, planning, implementation, and evaluation.
The most relevant nursing order for a patient who develops dyspnea
|A. Assert the patient on strict bed rest at all times|
|B. Maintain the patient in an orthopneic position as required|
|C. As needed administer oxygen at 24%.|
|D. Allow a 1-hour respite between activities|
Motivate chest expansion and keeps the abdominal organs from pressing against the diaphragm. Oxygen and bed rest at 24% would improve the oxygenation of the tissues and cells to prevent hypoxia.
The nurse observes that Mr. Nathan begins to have increased difficulty breathing. She elevates the bed to a high Fowler position to decreases his respiratory distress. The nurse documents this breathing as
Orthopnea is the difficulty of breathing. Tachypnea is abnormally rapid breathing characterized by between 12 and 20breaths. Eupnea is a resting respiratory rate.
#1. A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?
#2. The correct sequence for assessing the abdomen is
Because percussion and palpation can affect bowel motility and thus bowel sounds, they should follow auscultation in the abdominal assessment. Tympanic percussion, measurement of abdominal girth, and inspection are methods of assessing the abdomen. Assessing for distention, tenderness, and discoloration around the umbilicus can indicate various bowel-related conditions, such as cholecystitis, appendicitis, and peritonitis.
#3. High-pitched gurgles head over the right lower quadrant are
C is the correct answer. Hyperactive sounds indicate increased bowel motility; two or three sounds per minute indicate decreased bowel motility. Abdominal cramping with hyperactive, high pitched tinkling bowel sounds can indicate a bowel obstruction.
#4. A patient about to undergo abdominal inspection is best placed in which of the following positions?
C is the correct answer. The supine position (also called the dorsal position), in which the patient lies on his back with his face upward, allows for easy access to the abdomen. In the prone position, the patient lies on his abdomen with his face turned to the side. In the Trendelenburg position, the head of the bed is tilted downward to 30 to 40 degrees so that the upper body is lower than the legs. In the lateral position, the patient lies on his side.
#5. For a rectal examination, the patient can be directed to assume which of the following positions?
D is the correct answer. All of these positions are appropriate for a rectal examination. In the genupectoral (knee-chest) position, the patient kneels and rests his chest on the table, forming a 90-degree angle between the torso and upper legs. In Sims’ position, the patient lies on his left side with the left arm behind the body and his right leg flexed. In the horizontal recumbent position, the patient lies on his back with legs extended and hips rotated outward.
#6. During a Romberg test, the nurse asks the patient to assume which position?
B is the correct answer. During a Romberg test, which evaluates for sensory or cerebellar ataxia, the patient must stand with feet together and arms resting at the sides—first with eyes open, then with eyes closed. The need to move the feet apart to maintain this stance is an abnormal finding. 22. A. The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.
#7. If a patient’s blood pressure is 150/96, his pulse pressure is
A is the correct answer. The pulse pressure is the difference between the systolic and diastolic blood pressure readings – in this case, 54.
#8. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8 F (37.7 C) This temperature reading probably indicates
D is the correct answer. A slightly elevated temperature in the immediate preoperative or postoperative period may result from the lack of fluids before surgery rather than from infection. Anxiety will not cause an elevated temperature. Hypothermia is abnormally low body temperature.
#9. Which of the following parameters should be checked when assessing respirations?
D is the correct answer. The quality and efficiency of the respiratory process can be determined by appraising the rate, rhythm, depth, ease, sound, and symmetry of respirations.
#10. .A 38-year old patient’s vital signs at 8 a.m. are axillary temperature 99.6 F (37.6 C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
D is the correct answer. Under normal conditions, a healthy adult breathes in a smooth uninterrupted pattern 12 to 20 times a minute. Thus, a respiratory rate of 30 would be abnormal. A normal adult body temperature, as measured on an oral thermometer, ranges between 97° and 100°F (36.1° and 37.8°C); an axillary temperature is approximately one degree lower and rectal temperature, one degree higher. Thus, an axillary temperature of 99.6°F (37.6°C) would be considered abnormal. The resting pulse rate in an adult ranges from 60 to 100 beats/minute, so a rate of 88 is normal.
The physician orders a platelet count the nurse is responsible for
|A. Instructing the patient about this diagnostic test|
|B. Writing the order for this test|
|C. Giving the patient breakfast|
|D. All of the above|
A platelet count evaluates the number of platelets within the circulating blood volume. The nurse is liable for giving the patient breakfast at the scheduled time. The physician is liable for instructing the patient about the test and for writing the order for the test.
Mrs. Bong has been given a replica of her diet. A 500 mg low sodium diet include
|A. cheese sandwich wheat bread|
|B. Mashed potatoes and broiled chicken|
|C. A salad with oil and vinegar and olives|
|D. Chicken bouillon|
Mashed potatoes and broiled chicken are low in natural common salt. Ham, olives, and chicken bouillon contain large amounts of sodium and are contraindicated on a coffee sodium diet.