NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client's arm may be broken. Which immediate action should the nurse take?
Correct Answer: A
Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is external to a hospital, and a primary health care provider is called if the client is hospitalized. Vital signs would be taken, but this is not the immediate action. The primary health care provider rather than the nurse prescribes an x-ray examination. The nurse should remain with the client and provide realistic reassurance. Although the details of the fall are important, such a discussion is not an immediate need.
Question 2 of 5
The nurse caring for a child who has sustained a head injury notes that the primary health care provider has documented decorticate posturing. During the assessment of the child, the nurse notes the extension of the upper extremities and the internal rotation of the upper arms and wrists. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, what is the initial nursing action?
Correct Answer: D
Rationale: Decorticate (flexion) posturing refers to the flexion of the upper extremities and the extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate (extension) posturing involves the extension of the upper extremities with the internal rotation of the upper arms and wrists. The lower extremities will extend with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Although documentation is appropriate, it is not the initial action in this situation. The other options are not appropriate.
Question 3 of 5
A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
Question 4 of 5
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
Question 5 of 5
A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?
Correct Answer: B
Rationale: The FHR should be between 120 and 160 beats/min during pregnancy. An FHR of 100 beats/min would require that the primary health care provider be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the primary health care provider. Based on this information, eliminate the options that suggest inaccurate nursing actions.