NCLEX Practice Exam
NCLEX Select All That Apply (SATA) practice exam from NursesLabs covering topics like coagulation tests, polycythemia vera, and metered dose inhaler use—ideal for nursing students preparing for NCLEX-RN exam with multi-response questions.
Alice Edwards
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1 . A p a t i e n t is a d m i t t e d t o t h e s a m e d a y s u r g e r y u n i t for l i v e r b i o p s y . W h i c h o f t h e f o l l o w i n g l a b o r a t o r y
t e s t s a s s e s s e s c o a g u l a t i o n ? S e l e c t a l l t h a t a p p l y .
1 . Partial t h r o m b o p astin time.
2 . P r o t h r o m b i n t i m e .
3 . P l a t e l e t c o u n t .
4 . H e moglocii n
5 . Complete B l o o d C o u n t
6 . White B l o o d Cell C o u n t
A n s w e r : 1 , 2 , a n d 3
Frochr e m a i n time., p a r t i a l t h r o m b o a l a s t i n t i m e . a n d a l a t e l e t c o u n t are a I i n c l u d e d i n c o a g u l a t i o n studies. T h e h e m o g o a i n
l e v e l , t h o u g h important information p r i o r t o a n i n v a s i v e p r o c e d u r e l i k e l i v e r b i o p s y , d o e s n o t assess c o a g u a t i o n .
2 . A p a t i e n t is a d m i t t e d t o t h e h o s p i t a l w i t h s u s p e c t e d p o l y c y t h e m i a v e r a . W h i c h o f t h e f o l l o w i n g s y m p t o m s
i s c o n s i s t e n t with t h e d i a g n o s i s ? S e l e c t a l l that a p p l y .
1 . W e i g h t loss.
2 . I n c r e a s e d c l o t t i n g t i m e .
3 . H ype rtensian.
4 . Headaches.
A n s w e r : 2 , 3 , a n d 4
P o l y c y t h e m i a vera is a c o n d i t i o n i n w h i c h the b o n e m a r r o w p r o d u c e s too m a n y r e d a l o o d c e l s . T h i s causes a n i n c r e a s e i n
h e m a t o c r i t a n d v s e o s i t y o f the b o o d . P a t i e n t s c a n e x p e r i e n c e h e a d a c h e s , dizziness, a n d visual d i s t u r b a n c e s .
Cardio vascu a r effects i n c l u d e i n c r e a s e d b l o o d pressure a n d d e l a y e d c l o t t i n g t i m e . W e i g h t loss i s n o t a manifestation o f
p o l y c y t n e m i a vera.
Pafte
3 . T h e n u r s e i s t e a c h i n g t h e c l i e n t h o w t o u s e a m e t e r e d d o s e i n h a l e r ( M D I ) t o a d m i n i s t e r a C o r t i c o s t e r o i d
d r u g . W h i c h o f t h e f o l l o w i n g c l i e n t a c t i o n s i n d i c a t e s that h e i s u s i n g t h e M D I c o r r e c t l y ? S e l e c t a l l t h a t a p p l y .
1 . T h e i n h a l e r is h e l d u p r i g h t .
2 . H e a d i s t i l t e d d o w n while i n h a l i n g t h e m e d i c a t i o n
3 . C l i e n t v s its 5 m i n u t e s b e t w e e n puffe.
4 . M o u t h i s rinsed with water fol o w n g a d m i n i s t r a t i o n
5 . C l i e n t lies s u p i n e fa'- 1 5 m i n u t e s fo l o w i n g a d m i n i s t r a t i o n .
A n s w e r : 1 a n d 4 .
4 . T h e n u r s e is t e a c h i n g a c l i e n t with p o l y c y t h e m i a v e r a about p o t e n t i a l c o m p l i c a t i o n s f r o m t h i s d i s e a s e .
W h i c h m a n i f e s t a t i o n s w o u l d t h e n u r s e i n c l u d e i n t h e c l i e n t ' s t e a c h i n g p l a n ? S e l e c t a l l that a p p l y .
1 . H e a r i n g l o s s
2 . V i s u a l disturbance
3 . H e a d a c h e
4 . O r t h o p n e a
5 . G o u t
6 . W e i g h t loss
A n s i v e r s : 2 , 3 , 4 a n d 5 .
P o l y c y t h e m i a vera, a c o n d i t i o n i n w h i c h too m a n y RBCs a r e p r o d u c e d in t h e b l o o d s e r u m , c a n l e a d t o a n increase i n the
h e m a t o c r i t a n d hypervo e m i a , h y p e r v i s c o s i t y , a n d h y p e r t e n s i o n . S u b s e q u e n t l y , the c l i e n t c a n experience d i z z i n e s s ,
t i n n i t u s , visual d i s t u r b a n c e s , h e a d a c h e s , o r a feeling o f f u l l n e s s i n the h e a d . T h e c l i e n t m a y a s o e x p e r i e n c e
c a r d i o v a s c u l a r s y m p t o m s s u c h a s h e a r t f a i l u r e { s h o r t n e s s o f b r e a t h a n d o r t h o p n e a ) a n d i n c r e a s e d c l o t t i n g t i m e o r C N
s y m p t o m s o f a n i n c r e a s e d uric a c i d l e v e l s u c h a s p a i n f u l s w o l e n joints ( u s u a l y t h e o i g t o e ) . H e a r i n g loss a n d weight loss
are n o t manifestations a s s o c i a t e d with p o y c y t h e m a vera.
1 . A p a t i e n t is a d m i t t e d t o t h e s a m e d a y s u r g e r y u n i t for l i v e r b i o p s y . W h i c h o f t h e f o l l o w i n g l a b o r a t o r y
t e s t s a s s e s s e s c o a g u l a t i o n ? S e l e c t a l l t h a t a p p l y .
1 . Partial t h r o m b o p astin time.
2 . P r o t h r o m b i n t i m e .
3 . P l a t e l e t c o u n t .
4 . H e moglocii n
5 . Complete B l o o d C o u n t
6 . White B l o o d Cell C o u n t
A n s w e r : 1 , 2 , a n d 3
Frochr e m a i n time., p a r t i a l t h r o m b o a l a s t i n t i m e . a n d a l a t e l e t c o u n t are a I i n c l u d e d i n c o a g u l a t i o n studies. T h e h e m o g o a i n
l e v e l , t h o u g h important information p r i o r t o a n i n v a s i v e p r o c e d u r e l i k e l i v e r b i o p s y , d o e s n o t assess c o a g u a t i o n .
2 . A p a t i e n t is a d m i t t e d t o t h e h o s p i t a l w i t h s u s p e c t e d p o l y c y t h e m i a v e r a . W h i c h o f t h e f o l l o w i n g s y m p t o m s
i s c o n s i s t e n t with t h e d i a g n o s i s ? S e l e c t a l l that a p p l y .
1 . W e i g h t loss.
2 . I n c r e a s e d c l o t t i n g t i m e .
3 . H ype rtensian.
4 . Headaches.
A n s w e r : 2 , 3 , a n d 4
P o l y c y t h e m i a vera is a c o n d i t i o n i n w h i c h the b o n e m a r r o w p r o d u c e s too m a n y r e d a l o o d c e l s . T h i s causes a n i n c r e a s e i n
h e m a t o c r i t a n d v s e o s i t y o f the b o o d . P a t i e n t s c a n e x p e r i e n c e h e a d a c h e s , dizziness, a n d visual d i s t u r b a n c e s .
Cardio vascu a r effects i n c l u d e i n c r e a s e d b l o o d pressure a n d d e l a y e d c l o t t i n g t i m e . W e i g h t loss i s n o t a manifestation o f
p o l y c y t n e m i a vera.
Pafte
3 . T h e n u r s e i s t e a c h i n g t h e c l i e n t h o w t o u s e a m e t e r e d d o s e i n h a l e r ( M D I ) t o a d m i n i s t e r a C o r t i c o s t e r o i d
d r u g . W h i c h o f t h e f o l l o w i n g c l i e n t a c t i o n s i n d i c a t e s that h e i s u s i n g t h e M D I c o r r e c t l y ? S e l e c t a l l t h a t a p p l y .
1 . T h e i n h a l e r is h e l d u p r i g h t .
2 . H e a d i s t i l t e d d o w n while i n h a l i n g t h e m e d i c a t i o n
3 . C l i e n t v s its 5 m i n u t e s b e t w e e n puffe.
4 . M o u t h i s rinsed with water fol o w n g a d m i n i s t r a t i o n
5 . C l i e n t lies s u p i n e fa'- 1 5 m i n u t e s fo l o w i n g a d m i n i s t r a t i o n .
A n s w e r : 1 a n d 4 .
4 . T h e n u r s e is t e a c h i n g a c l i e n t with p o l y c y t h e m i a v e r a about p o t e n t i a l c o m p l i c a t i o n s f r o m t h i s d i s e a s e .
W h i c h m a n i f e s t a t i o n s w o u l d t h e n u r s e i n c l u d e i n t h e c l i e n t ' s t e a c h i n g p l a n ? S e l e c t a l l that a p p l y .
1 . H e a r i n g l o s s
2 . V i s u a l disturbance
3 . H e a d a c h e
4 . O r t h o p n e a
5 . G o u t
6 . W e i g h t loss
A n s i v e r s : 2 , 3 , 4 a n d 5 .
P o l y c y t h e m i a vera, a c o n d i t i o n i n w h i c h too m a n y RBCs a r e p r o d u c e d in t h e b l o o d s e r u m , c a n l e a d t o a n increase i n the
h e m a t o c r i t a n d hypervo e m i a , h y p e r v i s c o s i t y , a n d h y p e r t e n s i o n . S u b s e q u e n t l y , the c l i e n t c a n experience d i z z i n e s s ,
t i n n i t u s , visual d i s t u r b a n c e s , h e a d a c h e s , o r a feeling o f f u l l n e s s i n the h e a d . T h e c l i e n t m a y a s o e x p e r i e n c e
c a r d i o v a s c u l a r s y m p t o m s s u c h a s h e a r t f a i l u r e { s h o r t n e s s o f b r e a t h a n d o r t h o p n e a ) a n d i n c r e a s e d c l o t t i n g t i m e o r C N
s y m p t o m s o f a n i n c r e a s e d uric a c i d l e v e l s u c h a s p a i n f u l s w o l e n joints ( u s u a l y t h e o i g t o e ) . H e a r i n g loss a n d weight loss
are n o t manifestations a s s o c i a t e d with p o y c y t h e m a vera.
5 . W h i c h o f t h e f o l l o w i n g w o u l d b e p r i o r i t y a s s e s s m e n t d a t a t o g a t h e r from a c l i e n t w h o h a s b e e n d i a g n o s e d
with p n e u m o n i a ? S e l e c t a l l t h a t a p p l y .
1 . Auscultation o f breath s o u n d s
2 . A u s c u l t a t o n o f Dowel s o u n d s
3 . Presence o f c h e s t p a i n .
4 . Presence o f peripheral e d e m a
5 . Color o f n a i l b e d s
A n s w e r : 1 , 3 , 5 .
A r e s p i r a t o r y a s s e s s m e n t , vrfiich i n c l u d e s a u s c u l t a t i o n o f breath s o u n d s a n d assessing tne c o l o r o f the n a i l b e d s , s a
priority for c l i e n t s with p n e u m o n i a . Assessing for the presence o f c h e s t p a i n i s a l s o a n i m p o r t a n t r e s p i r a t o r y assessment
as chest p a i n c a n interfere with the c l i e n t s a b i l i t y t o breathe d e e p l y . A u s c u l t a t i n g b o w e l s o u n d s a n d assessing for
p e r i D h e r a l e d e m a m a y b e a p p r o p r i a t e a s s e s s m e n t s , but t h e s e a r e n o t p r i o r i t y assessments for the p a t i e n t with
p n e u m o n i a .
6 . T h e n u r s e i s t e a c h i n g a c l i e n t w h o h a s b e e n d i a g n o s e d with TB h o w t o a v o i d s p r e a d i n g t h e d i s e a s e t o
f a m i l y m e m b e r s . W h i c h s t a t e m e n t ( s ) b y t h e c l i e n t i n d i c a t e ( s ) t h a t h e h a s u n d e r s t o o d t h e n u r s e s
i n s t r u c t i o n s ? S e l e c t a l l t h a t a p p l y .
1 . " I will n e e d t o d i s p o s e o f m y o l d c l o t h i n g when I return h o m e . "
2 . " I s h o u l d a l w a y s c o v e r m y m o u t h a n d nose when sneezing."
3 . ' I t i s i m p o r t a n t that I isolate m y s e l f foom family v h e n p o s s i b l e . "
4 . ' I s h o u l d use p a p e r t i s s u e s t o c o u g h i n a n d d i s p o s e o f t h e m p r o p e r l y."
5 . " I c a n u s e r e g u l a r p l a t e a n d utensils w h e n e i r I eat." C O
A n s i v e r : 2 , 4 , 5 .
7 . T h e n u r s e is a d m i t t i n g a c l i e n t w i t h h y p o g l y c e m i a . I d e n t i f y t h e s i g n s a n d s y m p t o m s t h e n u r s e s h o u l d
e x p e c t . S e l e c t a l l t h a t a p p l y .
1 . Thirst
2 . P a l p i t a t i o n s
3 . D i a o h o r e s s
4 . Slurred s p e e c h
5 . H y p e r v e n t i l a t i o n
A n s i v e r : 2 , 3 , 4 .
P a l p t a t i o n s , a n a d r e n e r g i c s y m p t o m , o c c u r a s the g l u c o s e l e w i s fell; the s y m p a t h e t i c nervous s ystem i s activated a n d
eoinephrine a n d n o r e o i n e p h r i n e a r e secreted c a u s i n g t h i s response. D i a p h o r e s i s i s a s y m p a t h e t i c n e r v o u s s y s t e m
r e s p o n s e that o c c u r s a s e p i n e p h r i n e a n d n o r e p i n e p h r i n e a r e r e l e a s e d . S l u r r e d s p e e c h s a n e u r o g l y c o p e n i c symptom; a s
the b r a i n receives insufficient g l u c o s e , t h e a c t i i t y o f t h e CMS b e c o m e s d e p r e s s e d .
8 . W h i c h a d a p t a t i o n s s h o u l d t h e n u r s e c a r i n g for a c l i e n t with d i a b e t i c k e t o a c i d o s i s e x p e c t t h e c l i e n t t o
e x h i b i t ? S e l e c t a l l t h a t a p p l y :
1 . Sweating
2 . L o w PCO2
3 . R e t i n o p a t h y
4 . Acetone b r e a t h
5 . E l e v a t e d s e r u m b i c a r b o n a t e
Answer: 2 , 4 .
M e t a b o l i c a c i d o s i s i n i t i a t e s r e s p i r a t o r y c o m p e n s a t i o n i n the form o f K u s s m a u l respirations t o c o u n t e r a c t the effects o f
k e t o n e b u i l d u p , r e s u l t i n g i n a lowered PCO2. A fruity o d o r t o the b r e a t h ( a c e t o n e breath) o c c u r s vrfienthe ketone l e v e l i s
e l e v a t e d i n k e t o a c i d o s i s .
with p n e u m o n i a ? S e l e c t a l l t h a t a p p l y .
1 . Auscultation o f breath s o u n d s
2 . A u s c u l t a t o n o f Dowel s o u n d s
3 . Presence o f c h e s t p a i n .
4 . Presence o f peripheral e d e m a
5 . Color o f n a i l b e d s
A n s w e r : 1 , 3 , 5 .
A r e s p i r a t o r y a s s e s s m e n t , vrfiich i n c l u d e s a u s c u l t a t i o n o f breath s o u n d s a n d assessing tne c o l o r o f the n a i l b e d s , s a
priority for c l i e n t s with p n e u m o n i a . Assessing for the presence o f c h e s t p a i n i s a l s o a n i m p o r t a n t r e s p i r a t o r y assessment
as chest p a i n c a n interfere with the c l i e n t s a b i l i t y t o breathe d e e p l y . A u s c u l t a t i n g b o w e l s o u n d s a n d assessing for
p e r i D h e r a l e d e m a m a y b e a p p r o p r i a t e a s s e s s m e n t s , but t h e s e a r e n o t p r i o r i t y assessments for the p a t i e n t with
p n e u m o n i a .
6 . T h e n u r s e i s t e a c h i n g a c l i e n t w h o h a s b e e n d i a g n o s e d with TB h o w t o a v o i d s p r e a d i n g t h e d i s e a s e t o
f a m i l y m e m b e r s . W h i c h s t a t e m e n t ( s ) b y t h e c l i e n t i n d i c a t e ( s ) t h a t h e h a s u n d e r s t o o d t h e n u r s e s
i n s t r u c t i o n s ? S e l e c t a l l t h a t a p p l y .
1 . " I will n e e d t o d i s p o s e o f m y o l d c l o t h i n g when I return h o m e . "
2 . " I s h o u l d a l w a y s c o v e r m y m o u t h a n d nose when sneezing."
3 . ' I t i s i m p o r t a n t that I isolate m y s e l f foom family v h e n p o s s i b l e . "
4 . ' I s h o u l d use p a p e r t i s s u e s t o c o u g h i n a n d d i s p o s e o f t h e m p r o p e r l y."
5 . " I c a n u s e r e g u l a r p l a t e a n d utensils w h e n e i r I eat." C O
A n s i v e r : 2 , 4 , 5 .
7 . T h e n u r s e is a d m i t t i n g a c l i e n t w i t h h y p o g l y c e m i a . I d e n t i f y t h e s i g n s a n d s y m p t o m s t h e n u r s e s h o u l d
e x p e c t . S e l e c t a l l t h a t a p p l y .
1 . Thirst
2 . P a l p i t a t i o n s
3 . D i a o h o r e s s
4 . Slurred s p e e c h
5 . H y p e r v e n t i l a t i o n
A n s i v e r : 2 , 3 , 4 .
P a l p t a t i o n s , a n a d r e n e r g i c s y m p t o m , o c c u r a s the g l u c o s e l e w i s fell; the s y m p a t h e t i c nervous s ystem i s activated a n d
eoinephrine a n d n o r e o i n e p h r i n e a r e secreted c a u s i n g t h i s response. D i a p h o r e s i s i s a s y m p a t h e t i c n e r v o u s s y s t e m
r e s p o n s e that o c c u r s a s e p i n e p h r i n e a n d n o r e p i n e p h r i n e a r e r e l e a s e d . S l u r r e d s p e e c h s a n e u r o g l y c o p e n i c symptom; a s
the b r a i n receives insufficient g l u c o s e , t h e a c t i i t y o f t h e CMS b e c o m e s d e p r e s s e d .
8 . W h i c h a d a p t a t i o n s s h o u l d t h e n u r s e c a r i n g for a c l i e n t with d i a b e t i c k e t o a c i d o s i s e x p e c t t h e c l i e n t t o
e x h i b i t ? S e l e c t a l l t h a t a p p l y :
1 . Sweating
2 . L o w PCO2
3 . R e t i n o p a t h y
4 . Acetone b r e a t h
5 . E l e v a t e d s e r u m b i c a r b o n a t e
Answer: 2 , 4 .
M e t a b o l i c a c i d o s i s i n i t i a t e s r e s p i r a t o r y c o m p e n s a t i o n i n the form o f K u s s m a u l respirations t o c o u n t e r a c t the effects o f
k e t o n e b u i l d u p , r e s u l t i n g i n a lowered PCO2. A fruity o d o r t o the b r e a t h ( a c e t o n e breath) o c c u r s vrfienthe ketone l e v e l i s
e l e v a t e d i n k e t o a c i d o s i s .
9 . W h e n p l a n n i n g c a r e for a c l i e n t with u l c e r a t i v e colitis w h o i s e x p e r i e n c i n g s y m p t o m s , w h i c h c l i e n t c a r e
a c t i v i t i e s c a n t h e n u r s e a p p r o p r i a t e l y d e l e g a t e t o a u n l i c e n s e d a s s i s t a n t ? S e l e c t a l l t h a t a p p l y .
1 . Assessing t h e client's b o w e l s o u n d s
2 . P r o v i d i n g s k i n c a r e following b o w e l m o v e m e n t s
3 . E v a l u a t i n g t h e c l i e n t s response t o a n t i d i a r r h e a l m e d c a t i o n s
4 . M a i n t a i n i n g i n t a k e a n d o u t p u t r e c o r d s
5 . O b t a i n i n g the c i e n t s weight.
A n s w e r : 2 , 4 , a n d 5 .
T h e nurse c a n d e l e g a t e t h e folio wing basic care a c t i v i t i e s t o the u n l i c e n s e d assistant: p r o v i d i n g s k i n cane folllowing bowel
m o v e m e n t s , m a i n t a n i n g i n t a k e a n d o u t p u t r e c o r d s , a n d o ata i n in g the c l i e n t s weight. Assessing t h e c ient's b o w e l s o u n d s
a n d e v a l u a t i n g the c l i e n t s response t o m e d i c a t i o n are r e g i s t e r e d nurse a c t i v i t i e s t h a t c a n n o t b e d e l e g a t e d .
1 0 . V 4 i i c h o f t h e f o l l o w i n g n u r s i n g d i a g n o s e s would b e a p p r o p r i a t e for a c l i e n t with heart f a i l u r e ? S e l e c t a l l
t h a t a p p l y .
1 . Ineffective tissue p e r f u s i o n rotated t o d e c r e a s e d o e r i p h e r a l b l o o d flow s e c o n d a r y t o d e c r e a s e d c a r d i a c o u t o u t .
2 . Activity i n t o l e r a n c e related t o i n c r e a s e d cardiac o u t p u t .
3 . D e c r e a s e d cardiac o u t p u t rotated t o structural a n d f u n c t i o n a c h a n g e s .
4 . I m p a i r e d g a s e x c h a n g e related t o d e c r e a s e d s y m p a t h e t i c nervous s y s t e m activity.
A n s w e r : 1 a n d 3 .
HF is a r e s u l t o f structural a n d functional a b n o r m a l i t i e s o f the h e a r t tissue m u s c l e . T h e h e a r t m u s c l e b e c o m e s weak a n d
d o e s not a d e q u a t e l y p u m p t h e b l o o d o u t o f t h e c h a m b e r s . A s a r e s u l t , b l o o d p o o l s i n t h e left ventricle a n d backs u p i n t o L O
the left a t r i u m , a n d e v e n t u a l l y into the l u n g s . Therefore, g r e a t e r a m o u n t s o f b l o o d r e m a i n i n t h e ventricle after
contraction t h e r e b y d e c r e a s i n g cardiac output. I n a d d i t i o n , t h i s p o o l i n g leads t o t h r o m b u s formation a n d ineffective tissue
Page
p e r f u s i o n b e c a use o f t h e d e c r e a s e i n b l o o d flow t o the o t h e r o r g a n s a n d t i s s u e s o f t h e b o d y . T yoically, t h e s e d i e nts h a ve
a n e j e c t i o n fract o n o f less t h a n 5 0 % a n d pooriy t o l e r a t e a c t i v i t y . A c t i v i t y i n t o l e r a n c e i s related t o a d e c r e a s e , n o t
i n c r e a s e , i n c a r d i a c o u t p u t . G a s e x c h a n g e is i m p a r e d . H o w e v e r , the d e c r e a s e i n c a r d i a c o u t p u t triggers c o m p e n s a t o r y
m e c h a n i s m s , s u c h a s a n increase i n s y m p a t h e t c n e r v o u s s y s t e m a c t vity.
1 1 . W h e n c a r i n g for a c l i e n t with a c e n t r a l v e n o u s l i n e , w h i c h o f t h e f o l l o w i n g n u r s i n g a c t i o n s s h o u l d b e
i m p l e m e n t e d i n t h e p l a n o f c a r e f o r c h e m o t h e r a p y a d m i n i s t r a t i o n ? S e l e c t a l l t h a t a p p l y .
1 . V e r i f y p a t e n c y o f t h e line b y t h e p r e s e n c e o f a o l o o d return a t rogular interva s.
2 . I n s p e c t t h e i n s e r t i o n s i t e for s w e l l i n g , e r y t h e m a , o r d r a i n a g e .
3 . A d m i n i s t e r a c y t o t o x c a g e n t t o k e e p t h e r e g i m e n o n s c n e d u l e e v e n i f b l o o d return i s n o t p r e s e n t .
4 . I f u n a b l e t o a s p i r a t e b l o o d , reposition t h e c l i e n t a n d e n c o u r a g e t h e c l i e n t t o c o u g h .
5 . C o n t a c t the health care provider a b o u t verifying p a c e m e n t i f tne status is q u e s t i o n a b l e .
A n s w e r : 1 , 2 , 4 , 5 .
A major c o n c e r n with ntra v e n o u s a d m i n i s t r a t i o n o f c y t o t o x i c a g e n t s i s vessel i r r i t a t i o n o r e x t r a v a s a t i o n . T h e O n c o l o g y
N u r s i n g S o c i e t y a n d h o s p i t a l g u i d e l i n e s r e q u i r e frequent e v a l u a t i o n o f b l o o d return when a d m i n i s t e r i n g vesicant o r n o n
v e s i c a n t c h e m o t h e r a p y d u e t o the r i s k o f e xtra vasation. T h e s e g u i d e l i n e s a p p y t o p e r i p h e r a l a n d c e n t r a l venous l i n e s . I n
a d d i t i o n , c e n t r a l v e n o u s l i n e s m a y b e l o n g - t e r m v e n o u s a c c e s s d e vices. T h u s , d i f f i c u l t y drawing o r a s p i r a t i n g b l o o d m a y
i n d i c a t e t h e l i n e is a g a i n s t the vessel wall o r m a y i n d i c a t e the line h a s o c c l u s i o n . H a ving t h e c l i e n t c o u g h o r m o v e position
m a y c h a n g e the status o f t h e l i n e i f it is t e m p o r a r i l y a g a i n s t a vessel wall. O c c l u s i o n warrants more t h o r o u g h e v a l u a t i o n
via x - r a y s t u d y t o '.erify p l a c e m e n t i f the status i s q u e s t i o n a b l e a n d m a y r e q u i r e a d e c l o t t i n g r e g i m e n .
1 2 . A 2 0 - y e a r o l d c o l l e g e s t u d e n t h a s b e e n b r o u g h t t o t h e p s y c h i a t r i c hospital! b y h e r p a r e n t s . H e r a d m i t t i n g
d i a g n o s i s i s b o r d e r l i n e p e r s o n a l i t y d i s o r d e r . W h e n t a l k i n g with t h e p a r e n t s , w h i c h i n f o r m a t i o n w o u l d t h e
n u r s e e x p e c t t o b e i n c l u d e d i n t h e c l i e n t ' s h i s t o r y ? S e l e c t a l l t h a t a p p l y .
a c t i v i t i e s c a n t h e n u r s e a p p r o p r i a t e l y d e l e g a t e t o a u n l i c e n s e d a s s i s t a n t ? S e l e c t a l l t h a t a p p l y .
1 . Assessing t h e client's b o w e l s o u n d s
2 . P r o v i d i n g s k i n c a r e following b o w e l m o v e m e n t s
3 . E v a l u a t i n g t h e c l i e n t s response t o a n t i d i a r r h e a l m e d c a t i o n s
4 . M a i n t a i n i n g i n t a k e a n d o u t p u t r e c o r d s
5 . O b t a i n i n g the c i e n t s weight.
A n s w e r : 2 , 4 , a n d 5 .
T h e nurse c a n d e l e g a t e t h e folio wing basic care a c t i v i t i e s t o the u n l i c e n s e d assistant: p r o v i d i n g s k i n cane folllowing bowel
m o v e m e n t s , m a i n t a n i n g i n t a k e a n d o u t p u t r e c o r d s , a n d o ata i n in g the c l i e n t s weight. Assessing t h e c ient's b o w e l s o u n d s
a n d e v a l u a t i n g the c l i e n t s response t o m e d i c a t i o n are r e g i s t e r e d nurse a c t i v i t i e s t h a t c a n n o t b e d e l e g a t e d .
1 0 . V 4 i i c h o f t h e f o l l o w i n g n u r s i n g d i a g n o s e s would b e a p p r o p r i a t e for a c l i e n t with heart f a i l u r e ? S e l e c t a l l
t h a t a p p l y .
1 . Ineffective tissue p e r f u s i o n rotated t o d e c r e a s e d o e r i p h e r a l b l o o d flow s e c o n d a r y t o d e c r e a s e d c a r d i a c o u t o u t .
2 . Activity i n t o l e r a n c e related t o i n c r e a s e d cardiac o u t p u t .
3 . D e c r e a s e d cardiac o u t p u t rotated t o structural a n d f u n c t i o n a c h a n g e s .
4 . I m p a i r e d g a s e x c h a n g e related t o d e c r e a s e d s y m p a t h e t i c nervous s y s t e m activity.
A n s w e r : 1 a n d 3 .
HF is a r e s u l t o f structural a n d functional a b n o r m a l i t i e s o f the h e a r t tissue m u s c l e . T h e h e a r t m u s c l e b e c o m e s weak a n d
d o e s not a d e q u a t e l y p u m p t h e b l o o d o u t o f t h e c h a m b e r s . A s a r e s u l t , b l o o d p o o l s i n t h e left ventricle a n d backs u p i n t o L O
the left a t r i u m , a n d e v e n t u a l l y into the l u n g s . Therefore, g r e a t e r a m o u n t s o f b l o o d r e m a i n i n t h e ventricle after
contraction t h e r e b y d e c r e a s i n g cardiac output. I n a d d i t i o n , t h i s p o o l i n g leads t o t h r o m b u s formation a n d ineffective tissue
Page
p e r f u s i o n b e c a use o f t h e d e c r e a s e i n b l o o d flow t o the o t h e r o r g a n s a n d t i s s u e s o f t h e b o d y . T yoically, t h e s e d i e nts h a ve
a n e j e c t i o n fract o n o f less t h a n 5 0 % a n d pooriy t o l e r a t e a c t i v i t y . A c t i v i t y i n t o l e r a n c e i s related t o a d e c r e a s e , n o t
i n c r e a s e , i n c a r d i a c o u t p u t . G a s e x c h a n g e is i m p a r e d . H o w e v e r , the d e c r e a s e i n c a r d i a c o u t p u t triggers c o m p e n s a t o r y
m e c h a n i s m s , s u c h a s a n increase i n s y m p a t h e t c n e r v o u s s y s t e m a c t vity.
1 1 . W h e n c a r i n g for a c l i e n t with a c e n t r a l v e n o u s l i n e , w h i c h o f t h e f o l l o w i n g n u r s i n g a c t i o n s s h o u l d b e
i m p l e m e n t e d i n t h e p l a n o f c a r e f o r c h e m o t h e r a p y a d m i n i s t r a t i o n ? S e l e c t a l l t h a t a p p l y .
1 . V e r i f y p a t e n c y o f t h e line b y t h e p r e s e n c e o f a o l o o d return a t rogular interva s.
2 . I n s p e c t t h e i n s e r t i o n s i t e for s w e l l i n g , e r y t h e m a , o r d r a i n a g e .
3 . A d m i n i s t e r a c y t o t o x c a g e n t t o k e e p t h e r e g i m e n o n s c n e d u l e e v e n i f b l o o d return i s n o t p r e s e n t .
4 . I f u n a b l e t o a s p i r a t e b l o o d , reposition t h e c l i e n t a n d e n c o u r a g e t h e c l i e n t t o c o u g h .
5 . C o n t a c t the health care provider a b o u t verifying p a c e m e n t i f tne status is q u e s t i o n a b l e .
A n s w e r : 1 , 2 , 4 , 5 .
A major c o n c e r n with ntra v e n o u s a d m i n i s t r a t i o n o f c y t o t o x i c a g e n t s i s vessel i r r i t a t i o n o r e x t r a v a s a t i o n . T h e O n c o l o g y
N u r s i n g S o c i e t y a n d h o s p i t a l g u i d e l i n e s r e q u i r e frequent e v a l u a t i o n o f b l o o d return when a d m i n i s t e r i n g vesicant o r n o n
v e s i c a n t c h e m o t h e r a p y d u e t o the r i s k o f e xtra vasation. T h e s e g u i d e l i n e s a p p y t o p e r i p h e r a l a n d c e n t r a l venous l i n e s . I n
a d d i t i o n , c e n t r a l v e n o u s l i n e s m a y b e l o n g - t e r m v e n o u s a c c e s s d e vices. T h u s , d i f f i c u l t y drawing o r a s p i r a t i n g b l o o d m a y
i n d i c a t e t h e l i n e is a g a i n s t the vessel wall o r m a y i n d i c a t e the line h a s o c c l u s i o n . H a ving t h e c l i e n t c o u g h o r m o v e position
m a y c h a n g e the status o f t h e l i n e i f it is t e m p o r a r i l y a g a i n s t a vessel wall. O c c l u s i o n warrants more t h o r o u g h e v a l u a t i o n
via x - r a y s t u d y t o '.erify p l a c e m e n t i f the status i s q u e s t i o n a b l e a n d m a y r e q u i r e a d e c l o t t i n g r e g i m e n .
1 2 . A 2 0 - y e a r o l d c o l l e g e s t u d e n t h a s b e e n b r o u g h t t o t h e p s y c h i a t r i c hospital! b y h e r p a r e n t s . H e r a d m i t t i n g
d i a g n o s i s i s b o r d e r l i n e p e r s o n a l i t y d i s o r d e r . W h e n t a l k i n g with t h e p a r e n t s , w h i c h i n f o r m a t i o n w o u l d t h e
n u r s e e x p e c t t o b e i n c l u d e d i n t h e c l i e n t ' s h i s t o r y ? S e l e c t a l l t h a t a p p l y .
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