I hope the NCLEX question with rational helped my readers a lot. Hoping it helped i am posting some more question on NCLEX
21. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this answer?
a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be repeated during several consecutive weeks
d. A client with a positive smear will have to have a positive culture to confirm the diagnosis
22. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to
a. Blindness
b. Myopia
c. Retrolental fibroplasia
d. Uveitis
23. A nursing assessment for initial signs of hypoglycemia will include
a. Pallor, blurred vision, weakness, behavioral changes
b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils
24. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then
a. Discarded, then the collection begins
b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. Placed in a separate container and later added to the collection
25. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to
a. Hypoextend the vertebral column
b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. Allow the client to sit up and move without twisting his spine
26. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to
a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings
27. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis
28. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be
a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position
29. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is
a. pH 7.49, HCO3 24, PCO2 46
b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, PCO2 30
30. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to
a. Correct the hyperglycemia that occurs with acute renal failure
b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia
d. Force potassium into the cells to prevent arrhythmias
31. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care?
a. Edema of the stoma
b. Mucus in the drainage appliance
c. Redness of the stoma
d. Feces in the drainage appliance
32. A nursing care plan for a client with a suprapubic cystostomy would include
a. Placing a urinal bag around the tube insertion to collect the urine
b. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube
c. Catheter irrigations every 4 hours to prevent formation of
urinary stones
d. Limiting fluid intake to 1500 mL per day
33. For a client who has ataxia, which of the following tests would be performed to assess the ability to ambulate?
a. Kernig's
b. Romberg's
c. Riley-Day's
d. Hoffmann's
34. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding?
a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system
35. Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur following unresolved atelectasis is
a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism
36. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
21. Answer: b
Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a).
22. Answer: a
Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness.
23. Answer: a
Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia.
24. Answer: a
Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.
25. Answer: b
Rationale: The purpose of the tongs is to decompress the vertebral column through
hyperextending it. Both (a) and (c) are incorrect because they might cause further damage.
(d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated.
26. Answer: c
Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.
27. Answer: c
Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.
28. Answer: d
Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward.
29. Answer: d
Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.
30. Answer: b
Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed.
This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion.
31. Answer: d
Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus from the stoma.
32. Answer: b
Rationale: Allowing the client to void naturally will be done prior to removal of the
catheter to ensure adequate emptying of the bladder. Irrigations are not recommended,
as they increase the chances of the client developing a urinary tract infection. Any time a client has an indwelling catheter in place, fluids should be encouraged (unless contraindicated) to prevent stone formation.
33. Answer: b
Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.
34. Answer: a
Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc.
35. Answer: c
Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary embolism could result from deep vein thrombosis.
36. Answer: b
Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. This will not anchor the traction, keep the client from sliding down in bed, or prevent pressure areas.
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21. When a client asks the nurse why the physician says he "thinks" he has tuberculosis, the nurse explains to him that diagnosis of tuberculosis can take several weeks to confirm. Which of the following statements supports this answer?
a. A positive reaction to a tuberculosis skin test indicates that the client has active tuberculosis, even if one negative sputum is obtained
b. A positive sputum culture takes at least 3 weeks, due to the slow reproduction of the bacillus
c. Because small lesions are hard to detect on chest x-rays, x-rays usually need to be repeated during several consecutive weeks
d. A client with a positive smear will have to have a positive culture to confirm the diagnosis
22. The nurse is counseling a client with the diagnosis of glaucoma. She explains that if left untreated, this condition leads to
a. Blindness
b. Myopia
c. Retrolental fibroplasia
d. Uveitis
23. A nursing assessment for initial signs of hypoglycemia will include
a. Pallor, blurred vision, weakness, behavioral changes
b. Frequent urination, flushed face, pleural friction rub
c. Abdominal pain, diminished deep tendon reflexes, double vision
d. Weakness, lassitude, irregular pulse, dilated pupils
24. The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. This specimen is then
a. Discarded, then the collection begins
b. Saved as part of the 24-hour collection
c. Tested, then discarded
d. Placed in a separate container and later added to the collection
25. Following an accident, a client is admitted with a head injury and concurrent cervical spine injury. The physician will use Crutchfield tongs. The purpose of these tongs is to
a. Hypoextend the vertebral column
b. Hyperextend the vertebral column
c. Decompress the spinal nerves
d. Allow the client to sit up and move without twisting his spine
26. The most appropriate nursing intervention for a client requiring a finger probe pulse oximeter is to
a. Apply the sensor probe over a finger and cover lightly with gauze to prevent skin breakdown
b. Set alarms on the oximeter to at least 100 percent
c. Identify if the client has had a recent diagnostic test using intravenous dye
d. Remove the sensor between oxygen saturation readings
27. A client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a regular basis
28. A 55-year-old client with sever epigastric pain due to acute pancreatitis has been admitted to the hospital. The client's activity at this time should be
a. Ambulation as desired
b. Bedrest in supine position
c. Up ad lib and right side-lying position in bed
d. Bedrest in Fowler's position
29. Of the following blood gas values, the one the nurse would expect to see in the client with acute renal failure is
a. pH 7.49, HCO3 24, PCO2 46
b. pH 7.49, HCO3 14, PCO2 30
c. pH 7.26, HCO3 24, PCO2 46
d. pH 7.26, HCO3 14, PCO2 30
30. A client in acute renal failure receives an IV infusion of 10% dextrose in water with 20 units of regular insulin. The nurse understands that the rationale for this therapy is to
a. Correct the hyperglycemia that occurs with acute renal failure
b. Facilitate the intracellular movement of potassium
c. Provide calories to prevent tissue catabolism and azotemia
d. Force potassium into the cells to prevent arrhythmias
31. A client has had a cystectomy and ureteroileostomy (ileal conduit). The nurse observes this client for complications in the postoperative period. Which of the following symptoms indicates an unexpected outcome and requires priority care?
a. Edema of the stoma
b. Mucus in the drainage appliance
c. Redness of the stoma
d. Feces in the drainage appliance
32. A nursing care plan for a client with a suprapubic cystostomy would include
a. Placing a urinal bag around the tube insertion to collect the urine
b. Clamping the tube and allowing the client to void through the urinary meatus before removing the tube
c. Catheter irrigations every 4 hours to prevent formation of
urinary stones
d. Limiting fluid intake to 1500 mL per day
33. For a client who has ataxia, which of the following tests would be performed to assess the ability to ambulate?
a. Kernig's
b. Romberg's
c. Riley-Day's
d. Hoffmann's
34. A client admitted to a surgical unit for possible bleeding in the cerebrum
has vital signs taken every hour to monitor to neurological status. Which of the following neurological checks will give the nurse the best information about the extent of bleeding?
a. Pupillary checks
b. Spinal tap
c. Deep tendon reflexes
d. Evaluation of extrapyramidal motor system
35. Assessing for immediate postoperative complications, the nurse knows that a complication likely to occur following unresolved atelectasis is
a. Hemorrhage
b. Infection
c. Pneumonia
d. Pulmonary embolism
36. A young client is in the hospital with his left leg in Buck's traction. The
team leader asks the nurse to place a footplate on the affected side at the bottom of the bed. The purpose of this action is to
a. Anchor the traction
b. Prevent footdrop
c. Keep the client from sliding down in bed
d. Prevent pressure areas on the foot
21. Answer: b
Rationale: Answer b is correct because the culture takes 3 weeks to grow. Usually even very small lesions can be seen on x-rays due to the natural contrast of the air in the lungs; therefore, chest x-rays do not need to be repeated frequently (c). Clients may have positive smears but negative cultures if they have been on medication (d). A positive skin test indicates the person only has been infected with tuberculosis but may not necessarily have active disease (a).
22. Answer: a
Rationale: The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness.
23. Answer: a
Rationale: Weakness, fainting, blurred vision, pallor and perspiration are all common symptoms when there is too much insulin or too little food - hypoglycemia. The signs and symptoms in answers (b) and (c) are indicative of hyperglycemia.
24. Answer: a
Rationale: The first specimen is discarded because it is considered "old urine" or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.
25. Answer: b
Rationale: The purpose of the tongs is to decompress the vertebral column through
hyperextending it. Both (a) and (c) are incorrect because they might cause further damage.
(d) is incorrect because the client cannot sit up with the tongs in place; only the head of the bed can be elevated.
26. Answer: c
Rationale: Clients may experience inaccurate readings if dye has been used for a diagnostic test. Dyes use colors that tint the blood which leads to inaccurate readings.
27. Answer: c
Rationale: The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.
28. Answer: d
Rationale: The pain of pancreatitis is made worse by walking and supine positioning. The client is more comfortable sitting up and leaning forward.
29. Answer: d
Rationale: The client with acute renal failure would be expected to have metabolic acidosis (low HCO3) resulting in acid blood pH (acidemia) and respiratory alkalosis (lowered PCO2) as a compensating mechanism. Normal values are pH 7.35 to 7.45; HCO3 23 to 27 mEg; and PCO2 35 to 45 mmHg.
30. Answer: b
Rationale: Dextrose with insulin helps move potassium into cells and is immediate management therapy for hyperkalemia due to acute renal failure. An exchange resin may also be employed.
This type of infusion is often administered before cardiac surgery to stabilize irritable cells and prevent arrhythmias; in this case KC1 is also added to the infusion.
31. Answer: d
Rationale: The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum which has been resected from its anatomical position and now functions as a reservoir or conduit for urine. The proximal and distal ileal borders can be resumed. Feces should not be draining from the conduit. Edema and a red color of the stoma are expected outcomes in the immediate postoperative period, as is mucus from the stoma.
32. Answer: b
Rationale: Allowing the client to void naturally will be done prior to removal of the
catheter to ensure adequate emptying of the bladder. Irrigations are not recommended,
as they increase the chances of the client developing a urinary tract infection. Any time a client has an indwelling catheter in place, fluids should be encouraged (unless contraindicated) to prevent stone formation.
33. Answer: b
Rationale: Romberg's test is the ability to maintain an upright position without swaying when standing with feet close together and eyes closed. Kernig's sign, a reflex contraction, is pain in the hamstring muscle when attempting to extend the leg after flexing the thigh.
34. Answer: a
Rationale: Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc.
35. Answer: c
Rationale: Pneumonia is a major complication of unresolved atelectasis and must be treated along with vigorous treatment for atelectasis. Hemorrhage and infection are not related to this condition. Pulmonary embolism could result from deep vein thrombosis.
36. Answer: b
Rationale: The purpose of the footplate is to prevent footdrop while the client is immobilized in traction. This will not anchor the traction, keep the client from sliding down in bed, or prevent pressure areas.
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