NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: B

Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.

Correct Answer: C

Rationale: The correct action to help prevent a fire in a healthcare setting is to notify visitors or post signs indicating that oxygen is in use in certain areas. Oxygen is a combustible material, and awareness of its presence is crucial to prevent fire hazards. By informing all individuals in the facility about the use of oxygen through clear signs or notifications, the risk of improper use and potential fire accidents can be minimized.


Choice A is incorrect because using an adaptor when plugging in client equipment is not directly related to fire prevention.
Choice B is also incorrect as marking faulty equipment and using it until inspection does not directly address fire prevention.
Choice D is not a recommended action for fire prevention; storing extra equipment with supplies does not address the specific fire risk associated with oxygen use.

Correct Answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function.
Choice B is incorrect as the pulse rate typically decreases with age, rather than increases.
Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation.
Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

Correct Answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels.
Therefore, the correct answer is 'High blood sugar.'

Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.

Correct Answer: D

Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice
C) or using a foam swab only on the tongue (choice
B) may not provide the comprehensive mouth care necessary for patients in a coma.