a nurse is performing suctioning through an adult clients tracheostomy tube the nurse notes that the clients oxygen saturation is 89 and terminates th
Logo

Nursing Elites

NCLEX-PN

Nclex Exam Cram Practice Questions

1. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

2. When managing time effectively, which of the following stimuli should the nurse respond to first?

Correct answer: D

Rationale: The correct answer is to attend to the care needs of the returning postoperative client just exiting the elevator first. In a healthcare setting, patient care should always take precedence, especially for complex or unstable clients requiring immediate assessment and care. The physician's loud verbal direction, the nursing supervisor going to a meeting, and unit staff leaving on a break are important but do not involve direct patient care. Therefore, the nurse should prioritize responding to the returning postoperative client to ensure their immediate needs are met.

3. Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?

Correct answer: B

Rationale: In late-stage Alzheimer's disease, although verbal communication may be challenging or limited, it is essential to maintain communication through talking and non-verbal cues like touching. Limiting communication can lead to feelings of isolation and worsen the emotional well-being of the individual. Choices A, C, and D reflect appropriate care strategies by addressing toileting needs, oral care, and assistance with eating and drinking, which are crucial aspects of caregiving for a client with late-stage Alzheimer's disease.

4. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?

Correct answer: B

Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.

5. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

Similar Questions

A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?
All of the following are causes of vaginal bleeding in late pregnancy except:
When providing perineal care to a female client, how should the nurse perform the procedure?
Which of these statements is true regarding advance directives?
Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

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

NCLEX PN Premium
$149.99/ 90 days

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

Other Courses