a client is brought into the emergency room where the physician suspects that he has cardiac tamponade based on this diagnosis the nurse would expect a client is brought into the emergency room where the physician suspects that he has cardiac tamponade based on this diagnosis the nurse would expect
Logo

Nursing Elites

NCLEX NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?

Correct answer: Hypotension and distended neck veins

Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively. Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.

2. When planning care for an uninsured diabetic patient, which strategy should be a priority?

Correct answer: Follow evidence-based practice guidelines

Rationale: The priority when planning care for an uninsured diabetic patient should be to follow evidence-based practice guidelines. By adhering to standardized evidence-based guidelines, the nurse can help reduce healthcare disparities among different socioeconomic groups. While obtaining less expensive medications and assisting with dietary changes are important, the primary concern should be providing care that aligns with established standards of practice. Teaching about the impact of exercise is also valuable but may not be the priority when immediate care planning for an uninsured patient is considered.

3. A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?

Correct answer: Assess the patient's mental status for drowsiness or sleepiness.

Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.

4. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

Correct answer: They are able to think logically in organizing facts

Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.

5. As a nursing supervisor in a long-term care facility, you prioritize strict infection control prevention measures due to the understanding that the normal aging process weakens the body's defenses. Which theory of aging supports the necessity of strict infection control prevention measures?

Correct answer: B: The Immunological Theory of Aging

Rationale: The theory of aging that aligns with the need for strict infection control prevention measures is the Immunological Theory of Aging. This theory posits that aging leads to a decline in the body's immune defenses and a reduced ability of antibodies to protect against infections. The other theories do not directly address the impact of aging on the immune system. The Programmed Longevity Theory focuses on genetic changes affecting aging, the Endocrine Theory emphasizes hormonal changes, and the Rate of Living Theory relates longevity to the rate of oxygen metabolism.

Similar Questions

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?
A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99