NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 4
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
Question 2 of 4
The nurse is caring for a client on mechanical ventilation via an oral endotracheal tube. What are the possible causes of the high-pressure alarm sounding?
Correct Answer: A,B,C,E
Rationale: The high-pressure alarm sounds when the peak inspiratory pressure reaches the set alarm limit. Causes include obstruction of the endotracheal tube because of the client lying on the tube or water or a kink in the tubing; the client being anxious or fighting the ventilator; an increased amount of secretions in the airways or a mucous plug; the client coughing, gagging, or biting on the oral endotracheal tube; decreased airway size related to wheezing or bronchospasm; pneumothorax; and displacement of the artificial airway and the endotracheal tube slipping into the right main stem bronchus. The low-pressure alarm sounds when there is a leak or disconnection in the ventilator circuit or a leak in the client's artificial airway cuff.
Question 3 of 4
The clinic nurse is observing a student perform a complete physical assessment on a client. During the respiratory assessment, the clinic nurse determines that the student is using which physical assessment technique?
Correct Answer: C
Rationale:
To perform percussion, the nurse places the middle finger of the nondominant hand against the body's surface. The tip of the middle finger of the dominant hand strikes the top of the middle finger of the nondominant hand. Palpation is performed using the sense of touch. Inspection is the process of observation. Auscultation involves listening to the sounds produced by the body.
Question 4 of 4
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.
Question 5 of 4
The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?
Correct Answer: B
Rationale: The client should avoid activities like swimming, driving, or operating heavy equipment until cleared by the healthcare provider, as these could pose risks related to the ICD function or sudden cardiac events. The other statements reflect appropriate self-care measures: avoiding rough contact protects the insertion site, avoiding strenuous activities prevents triggering the ICD, and avoiding electromagnetic sources minimizes interference with the device.