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NCLEX-RN Free Practice Questions
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Question 1 of 20
1. Question
1 pointsA nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
Correct
Answer and Rationale:
Option 3 is Correct answer.
Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn’s body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).
Incorrect
Answer and Rationale:
Option 3 is Correct answer.
Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn’s body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn’s skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).
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Question 2 of 20
2. Question
1 pointsA nurse is assessing a newborn infant after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate?
Correct
Answer and Rationale:
Option 4 is Correct answer.
Rationale: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the physician. Because the findings identified in the question are normal, the nurse would document the assessment findings.
Test-Taking Strategy: Use the process of elimination. Note the strategic words small amount of bloody drainage. This should assist in directing you to option 4 because this is a normal occurrence after circumcision. If you had difficulty with this question, review the expected findings after circumcision
Incorrect
Answer and Rationale:
Option 4 is Correct answer.
Rationale: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the physician. Because the findings identified in the question are normal, the nurse would document the assessment findings.
Test-Taking Strategy: Use the process of elimination. Note the strategic words small amount of bloody drainage. This should assist in directing you to option 4 because this is a normal occurrence after circumcision. If you had difficulty with this question, review the expected findings after circumcision
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Question 3 of 20
3. Question
1 pointsA nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome?
Correct
Answer and Rationale:
Option 1 is Correct answer.
Rationale: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.
Test-Taking Strategy: Use the process of elimination. Recalling that acrocyanosis may be a normal sign in a newborn infant will assist in eliminating options 2 and 4. From the remaining options, you must be familiar with the signs of respiratory distress syndrome. Also, note the relationship between the diagnosis and the signs noted in option 1. If you had difficulty with this question, review the signs of respiratory distress syndrome
Incorrect
Answer and Rationale:
Option 1 is Correct answer.
Rationale: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.
Test-Taking Strategy: Use the process of elimination. Recalling that acrocyanosis may be a normal sign in a newborn infant will assist in eliminating options 2 and 4. From the remaining options, you must be familiar with the signs of respiratory distress syndrome. Also, note the relationship between the diagnosis and the signs noted in option 1. If you had difficulty with this question, review the signs of respiratory distress syndrome
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Question 4 of 20
4. Question
1 pointsA nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?
Correct
Answer and Rationale:
Option 3 is Correct answer.
Rationale: A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.
Test-Taking Strategy: Options 1 and 2 are comparable or alike in that they indicate hypoactivity of the newborn and can be eliminated. From the remaining options, recalling the pathophysiology associated with an infant born to a drug-addicted mother and that the newborn is irritable will assist you in eliminating option 4. Review assessment findings for the newborn of a drug-addicted mother if you had difficulty with this question.
Incorrect
Answer and Rationale:
Option 3 is Correct answer.
Rationale: A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.
Test-Taking Strategy: Options 1 and 2 are comparable or alike in that they indicate hypoactivity of the newborn and can be eliminated. From the remaining options, recalling the pathophysiology associated with an infant born to a drug-addicted mother and that the newborn is irritable will assist you in eliminating option 4. Review assessment findings for the newborn of a drug-addicted mother if you had difficulty with this question.
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Question 5 of 20
5. Question
1 pointsAnurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
Correct
Answer and Rationale:
Option 4 is Correct answer.
Rationale: Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions.
Incorrect
Answer and Rationale:
Option 4 is Correct answer.
Rationale: Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after delivery. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions.
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Question 6 of 20
6. Question
1 pointsA nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. The best response by the nurse would be:
Correct
Answer and Rationale:
Option 4 is Correct answer.
Rationale: Vitamin K is necessary for the body to synthesizecoagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K–deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn’s bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
Incorrect
Answer and Rationale:
Option 4 is Correct answer.
Rationale: Vitamin K is necessary for the body to synthesizecoagulation factors. Vitamin K is administered to the newborn to prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K–deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn’s bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
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Question 7 of 20
7. Question
1 pointsA nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse includes which intervention in the plan of care?
Correct
Answer and Rationale:
Option 2 is Correct answer.
Rationale: An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.
Test-Taking Strategy: Use knowledge regarding care of an infant born to an HIV-infected mother. Eliminate options 1 and 3 first because they are not associated specifically with the care of a potentially HIV-infected newborn. s356 UNIT V Maternity Nursing
Incorrect
Answer and Rationale:
Option 2 is Correct answer.
Rationale: An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.
Test-Taking Strategy: Use knowledge regarding care of an infant born to an HIV-infected mother. Eliminate options 1 and 3 first because they are not associated specifically with the care of a potentially HIV-infected newborn. s356 UNIT V Maternity Nursing
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Question 8 of 20
8. Question
1 pointsA nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is:
Correct
Answer and Rationale:
Option 2 is Correct answer.
Rationale: The newborn of a diabeticmother is at risk for hypoglycemia, so Risk for injury related to low blood glucose levels would be a priority nursing diagnosis. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Hyperthermia, risk for delayed development, and risk for aspiration are not expected problems.
Test-Taking Strategy: Note the strategic word priority. Read each option thoroughly and eliminate options 1, 3, and 4 because newborns of diabetic mothers are not at risk for these problems. Also, note the relationship of the word diabetic in the question and the word glucose in option 2. Review nursing interventions for newborns of diabetic mothers if you had difficulty with this question.
Incorrect
Answer and Rationale:
Option 2 is Correct answer.
Rationale: The newborn of a diabeticmother is at risk for hypoglycemia, so Risk for injury related to low blood glucose levels would be a priority nursing diagnosis. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Hyperthermia, risk for delayed development, and risk for aspiration are not expected problems.
Test-Taking Strategy: Note the strategic word priority. Read each option thoroughly and eliminate options 1, 3, and 4 because newborns of diabetic mothers are not at risk for these problems. Also, note the relationship of the word diabetic in the question and the word glucose in option 2. Review nursing interventions for newborns of diabetic mothers if you had difficulty with this question.
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Question 9 of 20
9. Question
1 pointsA nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion if which of the following is noted on assessment of the client?
Correct
Answer and Rationale:
Option 3 is Correct answer.
Rationale: Oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. Adverse reactions associated with administration of the medication are hyperstimulation of uterine contractions and nonreassuring fetal heart rate patterns. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
Incorrect
Answer and Rationale:
Option 3 is Correct answer.
Rationale: Oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. Adverse reactions associated with administration of the medication are hyperstimulation of uterine contractions and nonreassuring fetal heart rate patterns. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
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Question 10 of 20
10. Question
1 pointsA pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on assessment?
Correct
Answer and Rationale:
Option 2 is Correct answer.
Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L. Proteinuria of 3þ is an expected finding in a client with preeclampsia.
Test-Taking Strategy: Use the process of elimination and eliminate option 3 first because it is a normal finding. Next, eliminate option 4, knowing that the therapeutic serum level of magnesium is 4 to 7.5 mEq/L. From the remaining options, recalling that proteinuria of 3þ would be noted in a client with preeclampsia will direct you to the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question.
Incorrect
Answer and Rationale:
Option 2 is Correct answer.
Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L. Proteinuria of 3þ is an expected finding in a client with preeclampsia.
Test-Taking Strategy: Use the process of elimination and eliminate option 3 first because it is a normal finding. Next, eliminate option 4, knowing that the therapeutic serum level of magnesium is 4 to 7.5 mEq/L. From the remaining options, recalling that proteinuria of 3þ would be noted in a client with preeclampsia will direct you to the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question.
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Question 11 of 20
11. Question
1 pointsThe nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement, if made by the client, indicates that teaching about improving sleep is necessary?
Correct
Answer and Rationale:
Option 3 is correct:
Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest.
Incorrect
Answer and Rationale:
Option 3 is correct:
Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest.
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Question 12 of 20
12. Question
1 pointsThe nurse is providing instructions to a nursing assistant regarding care of an older client with hearing loss. The nurse tells the assistant that clients with a hearing loss:
Correct
Rationale: Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.
Test-Taking Strategy: Think about the age-related changes that occur in the older client. Recalling that the client with a hearing loss responds to low-pitched tones will direct you to option 3. If you had difficulty with this question, review the characteristics associated with presbycusis and hearing loss.
Incorrect
Rationale: Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.
Test-Taking Strategy: Think about the age-related changes that occur in the older client. Recalling that the client with a hearing loss responds to low-pitched tones will direct you to option 3. If you had difficulty with this question, review the characteristics associated with presbycusis and hearing loss.
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Question 13 of 20
13. Question
1 pointsThe home care nurse is visiting an older female client whose husband died 6 months ago. Which behavior by the client indicates ineffective coping?
Correct
Rationale: Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Option 1 is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.
Test-Taking Strategy: Note the subject, an ineffective coping behavior. Eliminate options 2, 3, and 4 because they are comparable or alike and are positive activities in which the individual is engaging to get on with her life. Review coping mechanisms in response to grief and loss if you had difficulty with this question.
Incorrect
Rationale: Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Option 1 is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.
Test-Taking Strategy: Note the subject, an ineffective coping behavior. Eliminate options 2, 3, and 4 because they are comparable or alike and are positive activities in which the individual is engaging to get on with her life. Review coping mechanisms in response to grief and loss if you had difficulty with this question.
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Question 14 of 20
14. Question
1 pointsThe nurse employed in a long-term care facility is caring for an older male client. Which nursing action contributes to encouraging autonomy in the client?
Correct
Rationale: Autonomy is the personal freedom to direct one’s own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. Option 4 is the only option that allows the client to be a decision maker.
Test-Taking Strategy: Use the process of elimination, focusing on the subject encouraging autonomy. Recalling the definition of autonomy will direct you to the correct option. Remember that giving the client choices is essential to promote independence. Review the concept of autonomy as it relates to the older client if you had difficulty with this question.
Incorrect
Rationale: Autonomy is the personal freedom to direct one’s own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. Option 4 is the only option that allows the client to be a decision maker.
Test-Taking Strategy: Use the process of elimination, focusing on the subject encouraging autonomy. Recalling the definition of autonomy will direct you to the correct option. Remember that giving the client choices is essential to promote independence. Review the concept of autonomy as it relates to the older client if you had difficulty with this question.
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Question 15 of 20
15. Question
1 pointsThe nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse explains that the best time to perform this exam is:
Correct
Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.
Incorrect
Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.
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Question 16 of 20
16. Question
1 pointsWhile performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which of the following best describes the sound of a heart murmur?
Correct
Rationale: A heart murmur is an abnormal heart sound and isdescribed as a gentle, blowing, swooshing sound. Lub-dubsounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial frictionrub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.
Test-Taking Strategy: Focus on the subject, characteristics of a murmur. Eliminate option 1 because it describes normal heart sounds. Next use the process of elimination recalling that a murmur occurs as a result of the manner in which the blood is flowing through the cardiac chambers and valves. This will direct you to option 3. Review the characteristics of a murmur if you had difficulty with this question.
Incorrect
Rationale: A heart murmur is an abnormal heart sound and isdescribed as a gentle, blowing, swooshing sound. Lub-dubsounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial frictionrub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.
Test-Taking Strategy: Focus on the subject, characteristics of a murmur. Eliminate option 1 because it describes normal heart sounds. Next use the process of elimination recalling that a murmur occurs as a result of the manner in which the blood is flowing through the cardiac chambers and valves. This will direct you to option 3. Review the characteristics of a murmur if you had difficulty with this question.
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Question 17 of 20
17. Question
1 pointsThe nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which of the following?
Correct
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.
Test-Taking Strategy: Focus on the subject, a conductive hearing loss. Noting the relationship of the word conductive in the question and transmission in option 3 will direct you to this option. Review the causes of a conductive and a sensorineural hearing loss if you had difficulty with this question.
Incorrect
Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.
Test-Taking Strategy: Focus on the subject, a conductive hearing loss. Noting the relationship of the word conductive in the question and transmission in option 3 will direct you to this option. Review the causes of a conductive and a sensorineural hearing loss if you had difficulty with this question.
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Question 18 of 20
18. Question
1 pointsThe nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse expects to note which of the following?
Correct
Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.
Test-Taking Strategy: Focus on the subject, the characteristics of Cheyne-Stokes respirations. Recalling that periods of apnea occur with this type of respiration will help direct you to correctly answer this question. Review the characteristics of Cheyne-Stokes respirations if you had difficulty with this question.
Incorrect
Rationale: Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.
Test-Taking Strategy: Focus on the subject, the characteristics of Cheyne-Stokes respirations. Recalling that periods of apnea occur with this type of respiration will help direct you to correctly answer this question. Review the characteristics of Cheyne-Stokes respirations if you had difficulty with this question.
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Question 19 of 20
19. Question
1 pointsA client with a diagnosis of asthma is admitted to the hospital with respiratory distress. What type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?
Correct
Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
Incorrect
Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
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Question 20 of 20
20. Question
1 pointsA nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which of the following is the most appropriate activity for this child?
Correct
Rationale: In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant.
Test-Taking Strategy: Note the age of the child, and think about the age-related activity that would be most appropriate. Eliminate options 1 and 2, knowing that they are most appropriate for the adolescent. From the remaining options, the word large in option 3 should provide you with the clue that this activity would be more appropriate for a child younger than age 5. If you had difficulty with this question, review the appropriate play activities for a preschooler.
Incorrect
Rationale: In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant.
Test-Taking Strategy: Note the age of the child, and think about the age-related activity that would be most appropriate. Eliminate options 1 and 2, knowing that they are most appropriate for the adolescent. From the remaining options, the word large in option 3 should provide you with the clue that this activity would be more appropriate for a child younger than age 5. If you had difficulty with this question, review the appropriate play activities for a preschooler.
Excellent to learn
d. A health care facility is required to provide a patient an attorney when the patient is signing a living will.