2024 NCLEX Daily Ten Question Practical Exercise 2

1. The home health nurse is performing a home safety assessment for an older adult client with a hearing impairment who uses a cane.
Which of the following client statements requires follow-up? Select all that apply.

A. “l enjoy taking baths for stress relief..
B. “l have a raised toilet seat in my bathroom.”
C. “My friend bought a beautiful new rug for my hallway.”
D. “l use a space heater for extra warmth on cold nights.”
E. “My daughter comes by once a week to fill my medication organizer.”

Correct Answer: A C D

Answer Explanation:

When conducting a home safety/hazard assessment, it is crucial to evaluate all rooms, entrances, and outdoor areas, tailoring the assessment to the specific needs of the client, such as hearing impairment. Key principles of home safety involve addressing various hazards. For instance, for clients with decreased mobility, installing a shower with grab bars or a walk-in bathtub is preferable to reduce the risk of falls compared to traditional bathtubs. Rugs and floor runners should be minimized, as they can increase the risk of falls, particularly for those with decreased sensory perception and mobility impairment, especially when using mobility aids. Additionally, space heaters should be avoided due to the fire hazard they pose. Clients with hearing impairment are especially vulnerable, as they may miss important environmental sounds, such as fire alarms. Therefore, visual fire alarms, which include flashing lights, are recommended. Lastly, safe food handling practices should be followed to mitigate the risk of consuming spoiled foods due to improper storage.

Advertisement

2. The emergency department charge nurse must transfer a client from the emergency department to the telemetry unit to make a bed available in the emergency department.
It would be most appropriate for the nurse to transfer out the client with

A. sepsis who has a blood pressure of 88/52
B. atrial fibrillation who has lV diltiazem ordered
C. ulcerative colitis who has a fever and diarrhea
D. chronic bronchitis who requires oxygen via nasal cannula

Correct Answer: B

Answer Explanation:

When assigning clients to specific nursing staff, it’s essential to align the client’s needs with the expertise and skills of the available nursing staff. Telemetry units are designed to provide care for clients who require cardiac monitoring without invasive interventions, such as intubation or hemodynamic monitoring (e.g., pulmonary artery catheter). Nurses working in telemetry units possess specialized knowledge concerning cardiac conditions and the interpretation of cardiac rhythms. For clients with dysrhythmias who are receiving vasoactive IV medications, continuous telemetry monitoring is necessary. As an example, a client with atrial fibrillation who requires a calcium-channel blocker (e.g., diltiazem) would be appropriately admitted to a telemetry unit.

Advertisement

3. The nurse has been made aware of the following client situations.
The nurse should first assess the client with

A. influenza reporting headache and malaise
B. sickle cell disease reporting itching and leg pain
C. pyelonephritis with persistent fever of 100.7 F(38.4 C)
D. congestive heart failure experiencing dyspnea on exertion

Correct Answer: B

Answer Explanation:

Sickle cell disease results in the production of rigid, sickle-shaped red blood cells, which can lead to the aggregation and blockage of blood vessels. This blockage, known as a sickle cell disease crisis, leads to reduced perfusion and tissue damage. During a crisis, most body systems can be affected, and symptoms can vary depending on the location of the blockage. Common symptoms include pain in the legs, hands, back, and chest due to ischemia and inflammation. Additionally, itching is a sign of elevated bilirubin resulting from the destruction of red blood cells. Due to the risk of life-threatening complications arising from impaired circulation, such as blood clots and organ damage, immediate assessment is necessary for this client. The nurse should be prepared to anticipate the need for interventions such as IV fluids, oxygen, and analgesics.

Advertisement

4. The nurse is notified of the following client situations.
It would be a priority for the nurse to follow up with the

A. 72-year-old male with pneumonia who is coughing up blood-tinged sputum
B. 36-year-old female with pancreatitis who has a temperature of 99.8 F (37.6 C)
C. 56-year-old female with a history of diabetes who reports indigestion and left shoulder pain
D. 36-year-old male with a history of Crohn disease with a new colostomy who reports skin irritation at the site

Correct Answer: C

Answer Explanation:

Atypical angina, which can manifest as symptoms like indigestion or shoulder pain, may indicate a possible myocardial infarction (MI), particularly in populations such as females and individuals with diabetes. Clients with diabetes are also at risk of presenting with asymptomatic (silent) MIs due to cardiac neuropathy. Therefore, immediate intervention is essential to prevent cardiac damage or cardiac arrest. Priority follow-up actions include promptly reporting symptoms to the healthcare provider, assessing for additional MI symptoms, such as chest pain, shortness of breath, diaphoresis, altered mental status, and fatigue, and conducting diagnostic testing, such as an electrocardiogram (ECG) and measuring troponin levels, to confirm the diagnosis.

Advertisement

5. The nurse is teaching a pregnant client about her new diagnosis of preeclampsia.
Which of the following information should the nurse include?

A. “lf you experience continuous heartburn, call the office for evaluation.”
B. “You will be on complete bed rest with bathroom privileges until after delivery.”
C. “Take your blood pressure once a week and report increased readings to your health care provider.”
D. “Don’t be alarmed if you experience blurred vision and headaches since it is expected with preeclampsia.”

Correct Answer: A

Answer Explanation:

Vasoconstriction resulting from preeclampsia can lead to poor organ perfusion, affecting vital organs such as the liver and kidneys. This hypoperfusion can cause liver inflammation and ischemia, which may manifest as continuous heartburn (e.g., epigastric pain). It’s crucial for the client to promptly notify the healthcare provider when experiencing continuous heartburn, as it could indicate severe disease or disease progression, such as the development of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets).

Advertisement

6. The nurse in the inpatient psychiatric unit is leading a support group for clients.
It would be a priority for the nurse to intervene if the client with

A. schizophrenia has not spoken and is staring intently at the corner of the room
B. major depressive disorder is expressing feelings of isolation and loneliness with the group
C. generalized anxiety disorder has moved to the back of the room and is engaging in deep breathing exercises
D. histrionic personality disorder is saying that another group member’s symptoms are not severe enough to beattending the session

Correct Answer: D

Answer Explanation:

Vasoconstriction resulting from preeclampsia can lead to poor organ perfusion, affecting vital organs such as the liver and kidneys. This hypoperfusion can cause liver inflammation and ischemia, which may manifest as continuous heartburn (e.g., epigastric pain). It’s crucial for the client to promptly notify the healthcare provider when experiencing continuous heartburn, as it could indicate severe disease or disease progression, such as the development of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets).

Advertisement

7. The nurse is preparing to administer digoxin to a client with heart failure.
Which of the following laboratory test results would the nurse review before administering the medication?

A. Sodium level
B. Platelet count
C. Potassium level
D. B-type natriuretic peptide

Correct Answer: C

Answer Explanation:

Digoxin, a cardiac glycoside utilized for heart failure and atrial arrhythmias, operates by inhibiting the sodium-potassium pump, leading to an accumulation of intracellular calcium and sodium. This elevated intracellular calcium enhances myocardial contractility (positive inotropy) and increases parasympathetic (vagal) activity, thereby reducing heart rate (negative chronotropy). Notably, both digoxin and potassium compete for binding sites on the sodium-potassium pump. In the presence of hypokalemia, digoxin can more readily bind to these sites, heightening the risk of digoxin toxicity. Therefore, it is crucial to ensure the client has a normal potassium level before administering digoxin. Signs of digoxin toxicity encompass gastrointestinal symptoms (nausea, vomiting, diarrhea), central nervous system effects (confusion, visual disturbances like yellow-green halos), and cardiac disturbances (arrhythmias, bradycardia).

Advertisement

8. The nurse has taught a client who is newly prescribed pyridostigmine for myasthenia gravis (MG).
Which of the following statements by the client would indicate a correct understanding of the teaching?

A. “| will wait to take this medication until 1 hour after l eat a meal.”
B. “I can stop taking this medication if it makes me feel sick to my stomach.”
C. “Taking this medication as prescribed can reverse my myasthenia gravis.”
D. “I should notify my primary health care provider if l experience excess sweating.”

Correct Answer: D

Answer Explanation:

Myasthenia gravis (MG) is a chronic autoimmune condition characterized by the destruction of acetylcholine receptors, leading to muscle weakness, dysphagia, double vision, and ptosis. Antimyasthenic medications such as pyridostigmine and neostigmine work by inhibiting acetylcholinesterase, thereby increasing the availability of acetylcholine in the neuromuscular junction, ultimately enhancing muscle strength. However, this can lead to cholinergic toxicity, marked by an overstimulation of the parasympathetic nervous system, resulting in “wet” symptoms opposite to those of anticholinergic toxicity. Signs of cholinergic toxicity can be recalled using the mnemonic SLUDGE (salivation, lacrimation, urination, diaphoresis, gastrointestinal distress [diarrhea], emesis). Clients experiencing cholinergic toxicity are at risk for severe bradycardia and bronchoconstriction and should promptly notify their healthcare provider.

Advertisement

9. The nurse is talking with a client who is being discharged from the hospital after coronary angiography for a myocardial infarction.
Which of the following statements by the client would require follow-up?

A. “l will gradually build up my activity to 150 minutes of brisk walking weekly.”
B. “| will set an alarm to take clopidogrel and aspirin at the same time every day.”
C. “I can resume sexual activity once l am able to comfortably climb 2 flights of stairs.”
D. “I can take naproxen to help with any aches and pains from my new exercise routine.”

Correct Answer: D

Answer Explanation:

After experiencing a myocardial infarction (MI), individuals are advised to implement several lifestyle adjustments to aid recovery and prevent future cardiac events. These changes include engaging in regular physical activity, with the American Heart Association (AHA) recommending a gradual buildup to at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous activity weekly. Additionally, post-MI medication adherence is crucial and typically involves taking a statin to prevent coronary thrombosis, as well as 6-12 months of dual-antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel or ticagrelor. It is also imperative to avoid non-steroidal anti-inflammatory drugs (NSAIDs) other than aspirin, as they heighten the risk of MI, kidney damage, and bleeding, particularly for individuals with cardiovascular or renal disease, or those taking anticoagulants or antiplatelet medications such as clopidogrel and aspirin.

Advertisement

10. The nurse is caring for a client who has a crush injury to the left lower leg.
It would be a priority for the nurse to monitor the client’s

A. pain level
B. urinary output
C. oral temperature
D. pedal pulse strength

Correct Answer: C

Answer Explanation:

Clients with extremity injuries, such as crush injuries or fractures, are susceptible to acute compartment syndrome, a condition in which swelling elevates pressure within the affected limb, impeding arterial blood flow and posing a risk of tissue necrosis and limb loss. Early signs of compartment syndrome include a decrease in pedal pulse strength, making it crucial for nurses to prioritize the assessment of pedal pulse strength. Continuous monitoring for the “6 Ps” is essential to identify signs of compartment syndrome: pain out of proportion to the injury, paresthesia, pallor, pulselessness, pressure, and paralysis. Treatment typically involves a fasciotomy to alleviate pressure and restore adequate perfusion.

Advertisement

Leave A Comment?