Nclex questions with rationale PDF

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practice questions with rationales...

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NF 320 NCLEX CHALLENGE #1 2020 1. A patient has had an ischemic stroke and has been admitted to your unit. You know the importance of the principles of body alignment and correct positioning to stroke victims. What would you do to prevent joint deformities? a. Place the patient in the prone position, laying flat, for 30 minutes/day b. Assist the patient in acutely flexing the thigh to promote movement c. Place a pillow in the axilla when there is limited external rotation d. Place patient's hand in pronation Rationale: Being completely flat is not ideal. A pillow under the pelvis would promote hyperextension. Acutely flexing would not promote venous return. A pillow under the axilla would keep the affected arm away from the body. 2. You are preparing discharge teaching for a patient who is being discharged after a hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient? a. Intermittent seizures can be expected. b. Take ibuprofen for complaints of a serious headache. c. Take antihypertensive medication as ordered. d. Drowsiness is normal for the first week after discharge. Rationale: ibuprofen increases risk for bleeding, the other two statements are not true. You want to take the medication to control blood pressure 3. You are the night shift nurse caring for a patient who had a craniotomy that morning. The patient becomes disoriented, can't sleep, and begins to hallucinate. The nurse knows that the patient is exhibiting symptoms of what? a. Sundowning b. Postoperative syndrome c. Cerebral salt-wasting syndrome d. Korsakoff's syndrome Rationale: Sundowning is a pattern of sadness, agitation, fear, delusions and hallucinations that occurs in some dementia patients just before nightfall. Korsakoff’s is an amnestic disorder caused by thiamine (vitamin B1) deficiency typically associated with prolonged use of alcohol 4. You are admitting a patient with a diagnosis of a gastrointestinal bleed who is in the compensatory stage of shock. You know that an early sign that accompanies initial shock is what? a. Increased urine output b. Decreased heart rate c. Hyperactive bowel sounds d. Cool, clammy skin Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin & kidneys, to the brain and heart to ensure adequate blood supply. The patient's skin is cool & clammy; blood vessels vasoconstrict, the HR increases, bowel sounds are hypoactive, & the UO decreases. 5. A patient is receiving dopamine, a vasoactive drug used for shock, to increase her stroke volume. What should the nurse be aware of when monitoring a vasoactive drug? a. The drug should be discontinued immediately after blood pressure increases. b. The drug dose should be weaned down prior to discontinuing. c. The drug may cause respiratory alkalosis.

d. The drug reduces oxygen demands of the heart. Rationale: When vasoactive medications are discontinued, they should never be stopped abruptly because this could cause severe hemodynamic instability, perpetuating the shock state. 6. A nurse in the ICU receives report from the nurse in the emergency department about a new patient being admitted with a neck injury he received while diving into a lake. The emergency-department nurse reports that his blood pressure is 85/54, heart rate is 53 beats per minute, and his skin is warm and dry. What does the ICU nurse recognize that that patient is probably experiencing? a. Anaphylactic shock b. Neurogenic shock c. Septic shock d. Hypovolemic shock Rationale: Neurogenic shock can be caused by spinal cord injury & s/s include a low bp; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss. 7. You are transferring a patient who is in the progressive stage of shock into ICU from your medicalsurgical unit. You are aware that the shock affects many organ systems and that nursing management of the patient will focus on what? a. Reviewing the cause of shock and trying to limit the progression b. Assessing and understanding shock and the significant changes in assessment data to guide the plan of care c. Giving the prescribed treatment but shifting focus to providing family time as the pt is unlikely to survive d. Giving progressive care to the patient and family using critical pathways for shock therapy Rationale: Nursing care of patients in the progressive stage of shock requires expertise in assessing and understanding shock and the significance of changes in assessment data. Early interventions are essential to the survival of patients in shock; thus, suspecting that a patient may be in shock and reporting subtle changes in assessment are imperative. Psychosocial needs, such as coping, are important considerations, but they are not prioritized over physiologic health. 8 You are caring for a patient in the ICU who is suffering from multiple organ dysfunction syndrome (MODS). What should your plan of care focus on? a. Encouraging the family to stay hopeful and educating the family to the fact that, in most cases, the prognosis is good b. Encouraging the family to leave the hospital and to take time for themselves as care of MODS patients may last for years c. Promoting communication with the patient and family along with addressing end-of-life issues d. Discussing organ donation on a # of different occasions to allow the family time to adjust to the idea Rationale: Promoting communication with the patient and family is a critical role of the RN w/ a patient in progressive shock. It is important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the patients wishes. Many cases of MODS result in death and the life expectancy of patients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option

9. Your patient is in hypovolemic shock. You know that antidiuretic hormone (ADH) plays a role during hypovolemic shock. What assessment finding will you likely observe related to the role of the antidiuretic hormone (ADH) during hypovolemic shock? a. Increased hunger b. Decreased thirst c. Decreased urinary output d. Increased capillary perfusion Rationale: During hypovolemic shock, a state of hypernatremia occurs. Hypernatremia stimulates the release of ADH by the pituitary gland. ADH causes the kidneys to retain water to raise blood volume & bp. In a hypovolemic state the body shifts blood away from anything that is not a vital organ, so hunger is not an issue; thirst is increased as the body tries to increase fluid volume; and capillary profusion decreases as the body shunts blood away from the periphery and to the vital organs. 10. You are caring for a patient in the ICU whose condition is deteriorating. You receive orders for dopamine, which is an intravenous vasoactive drug. What would be your priority assessment and interventions specific to the administration of vasoactive medications? a. Frequent vitals, monitoring the central line site, and providing accurate drug titration b. Reviewing rx , performing a focused cardiovascular assessment, & providing patient education c. Reviewing the laboratory findings, monitoring urine output, and assessing for peripheral edema d. Routine vitals, monitoring the peripheral IV site, and providing early discharge instructions Rationale: When vasoactive rx are administered, VS must be monitored frequently (at least q15min until stable, or more often if indicated); should be administered through a central venous line because infiltration and extravasation of some vasoactive rx can cause tissue necrosis and sloughing. An IV pump should be used to ensure that the rx are delivered safely and accurately. b is important but not specific to the administration of IV vasoactive drugs. C is not the priority and early discharge instructions would be inappropriate in this time of crisis. 11. As a member of the stroke team at your institution, you know that the contraindications for thrombolytic therapy include what? Select all that apply. a. INR above 1.0 b. Recent intracranial pathology c. Symptom onset greater than 2 hours prior to admission d. Current anticoagulation therapy e. Symptom onset greater than 3 hours prior to admission Rationale: anticoagulants will result in thinning of the blood. In combination with thrombolytic therapy the risk for bleeding increases. Recent intracranial pathology already suggests hemorrhage. 12. Patients in shock can experience fluid replacement complications. What does the nurse monitor the patient for? Select all that apply. a. Hypovolemia b. Difficulty breathing c. Cardiovascular overload d. Pulmonary edema e. Hypoglycemia Rationale: RN should monitor the patient closely for cardiovascular overload, signs of difficulty breathing, and pulmonary edema. Hypovolemia is what necessitates fluid replacement, and hypoglycemia is not a central concern with fluid replacement.

References: Hinkle, J. L., Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarths textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer. Sudjian, E. (2019, January 17). Wernicke-Korsakoff syndrome. Retrieved November 06, 2020, from https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospitalmedicine/wernicke-korsakoff-syndrome/...