NGN/NCLEX RN Prep Questions/Rationales with correct answers rated 100%

NGN/NCLEX RN Prep
Questions/Rationales
with correct answers
rated 100%



A client with a peripherally inserted central
catheter (PICC) in the right upper extremity
suddenly exhibits chest pain, dyspnea,
hypotension, and tachycardia. The nurse suspects
an embolism related to the PICC line. What
should the nurse do?For each action, click to
specify whether the action would be:Indicated: an
action that the nurse should take to resolve the
problemNon-essential: an action that the nurse
could take without harming the client, but the
action would not be likely to address the
problemContraindicated: an action that could
harm the client and should not be taken - ANSAction
Assess for fever
Non-essential
Assess for chest pain
Indicated
Assess for cyanosis
Indicated
Turn the client to the left side
Indicated
Position the client so the feet are lower than the
head
Contraindicated
Administer oxygen
Indicated
Place the client on continuous vital sign
monitoring
Indicated
Notify the primary health care provider
Indicated
Rationale:When a client has any type of central
venous catheter, there is a risk for breaking of the
catheter, dislodgement of a thrombus, or entry of
air into the circulation, all of which can lead to an
embolism. Signs and symptoms that this
complication is occurring include sudden chest
pain, dyspnea, tachypnea, hypoxia, cyanosis,
hypotension, and tachycardia, and the nurse
would assess for these findings. If this occurs, the
nurse should clamp the catheter, place the client
on the left side with the head lower than the feet
(not the feet lower than the head) to trap the
embolism in the right atrium of the heart,
administer oxygen, and notify the primary health
care provider. Continuous vital sign monitoring
should also be done to note for changes in the
client's condition. There is no reason for assessing
for a fever at this time.
The nurse notes the presence of a P wave, QRS
complex, flattened T waves, and occasional U
waves on a client's cardiac monitor screen. Fill in
the correct missing information by choosing from
the lists of options in the drop-down menus. -
ANS-The nurse should suspect
Your Answer: hypokalemiaCorrect Answer:
hypokalemia
because of the
Your Answer: flattened T waves and occasional U
wavesCorrect Answer: flattened T waves and
occasional U waves
Rationale:Cardiac changes in hypokalemia
include impaired repolarization, resulting in a
flattening of the T wave and eventually the
emergence of a U wave. Therefore, the nurse
should suspect hypokalemia. The incidence of
potentially lethal ventricular dysrhythmias is
increased in hypokalemia. The nurse should
immediately assess the client's vital signs and
cardiac status for signs of hypokalemia. The nurse
should also check the client's most recent serum
potassium level and then contact the primary
health care provider to report the findings and
obtain prescriptions to treat the hypokalemic
state.
The nurse is preparing a client for a chest x-ray
and notes that the client is wearing a religious
medal on a chain around the neck. What should
the nurse do with regard to this personal item?
Click to highlight the correct answer from the
options provided. - ANS-The nurse should: (Select
1 option)
✓Ask the client if the chain and medal can be
removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural
significance.
Rationale:Before certain diagnostic procedures, it
is typical to have a client remove personal objects
that are worn on the body because of client safety
and the possibility of compromising test results.
Therefore, the nurse should ask the client about
the significance of such an item and its removal
because it may have cultural or spiritual
significance. If so, the nurse should ask the client
if the item can be either removed temporarily or
placed on another part of the body during the
procedure if appropriate.