Kaplan NCLEX Readiness Exam
Terms in this set (180)
The nurse cares for a client
with a cuffed tracheostomy
tube. Before performing oral
care, the nur
... [Show More] se notes that the
client's tracheostomy cuff is
inflated. Which of the following
is the MOST appropriate action
for the nurse to take?
1. Leave the cuff inflated and
suction through the
tracheostomy.
2. Deflate the cuff and suction
through the tracheostomy
tube.
3. Inflate the cuff pressure to
40 mm Hg before suctioning.
4. Adjust the wall suction
pressure to 160 to 180 mm Hg
before suctioning.
1) CORRECT - Implementation: outcome desired;
cuff inflation decreases the risk of aspiration; cuff
position and pressure should be assessed
frequently; swallowing and breathing will cause
tracheostomy tube movement
2) Implementation: outcome not desired;
accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff
pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher
pressures
4) Implementation: outcome not desired; increases
the risk of trauma to lower airways3/16/2021 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
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A young adult brings a friend
to the emergency department
and states that the friend has
been using heroin. Which
action by the nurse is the
MOST appropriate?
1. Assess pupil size and
reactivity.
2. Assess oxygen saturation
levels.
3. Palpate dorsalis pedis
pulses.
4. Ask the client if he knows
today's date.
1) Assessment: outcome not priority but may be
appropriate; pinpoint pupils are a sign of heroin
overdose
2) CORRECT - Assessment: outcome priority;
shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
3) Assessment: outcome not priority; most
important to assess airway and breathing
4) Assessment: outcome not priority but may be
appropriate; drowsiness and euphoria may be seen;
not priority
The client tells the clinic nurse
that the client is thinking about
using nicotine polacrilex
(Nicorette). Which question is
MOST important for the nurse
to ask?
1. "Have you tried other
methods to stop smoking?"
2. "How long have you been
smoking?"
3. "Have you ever had chest
pain?"
4. "Do you have a partial dental
bridge?"
1) Assessment: outcome not priority but may be
appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be
appropriate; should be assessed for further
teaching
3) CORRECT - Assessment: outcome priority; action
of nicotine is vasoconstriction; increases heart rate
and myocardial oxygen consumption; increased risk
of angina and myocardial infarction
4) Assessment: outcome may be appropriate but
not priority; gum is place between cheek and gums;
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The nurse cares for the client
with a client controlled
analgesia (PCA) pump. The
nurse determines that the client
has pressed the button 11 times
and received 6 doses of
morphine during the last hour.
Which is the MOST appropriate
action for the nurse to take?
1. Assess the patency of the
PCA IV tubing.
2. Determine the client's
understanding of the PCA
pump function.
3. Obtain an order to begin a
PCA infusion of fentanyl.
4. Ask the client to describe the
pain.
1) Assessment: outcome not priority but may be
appropriate; if tubing is obstructed, alarm is
activated
2) Assessment: outcome may be appropriate but
not priority; more important to determine pain level,
description of the pain, region and radiation of the
pain, and relieving factors
3) Implementation: outcome not desired; more
important to assess severity of pain and pain relief
first
4) CORRECT - Assessment: outcome priority; must
validate that client is in pain before implementation3/16/2021 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
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A pregnant woman receives an
epidural anesthetic. After
administration of the epidural
anesthetic, the client's blood
pressure changes from 120/84
to 94/50. Which action by the
nurse is MOST appropriate?
1. Place the client flat on her
back.
2. Elevate the head of the bed
30 degrees.
3. Place the client on her left
side with her legs flexed.
4. Place the client supine with
the foot of the bed elevated.
1) Implementation: outcome not desired; no
increase in venous return
2) Implementation: outcome not desired; will
decrease venous return
3) CORRECT - Implementation: outcome desired;
will increase venous return and cardiac output; fetal
pressure on inferior vena cava reduced
4) Implementation: outcome not desired; elevation
of legs will increase venous return, but fetal
pressure on vena cava will prevent blood return to
heart
A nursing order, "Increase fluid
intake" is written for a client
diagnosed with dehydration.
Which finding BEST indicates
improving fluid status?
1. Urinary output of 1,500 mL in
24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in
24 hours.
4. Blood pressure of 100/82.
1) CORRECT - Assessment: outcome priority;
increased amounts of antidiuretic hormone
secreted; urine output decreased and concentrated
2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
3) Assessment: outcome not priority; normal intake
is 1,500 mL in 24 hours
4) Assessment: outcome not priority; normal BP is
120/80 [Show Less]
