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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q522-Q527):
NEW QUESTION # 522
The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be:
- A. Remind the husband that the physician wrote an order not to resuscitate.
- B. Call a code and proceed with cardiopulmonary resuscitation.
- C. Call the physician and inform him that the client has expired.
- D. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts.
Answer: B
Explanation:
Explanation
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
NEW QUESTION # 523
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
- A. Assess quantity of fluid.
- B. Assess color and odor of fluid.
- C. Document on fetal monitor strip and chart.
- D. Assess fetal heart rate (FHR).
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
NEW QUESTION # 524
The initial treatment for a client with a liquid chemical burn injury is to:
- A. Inject calcium chloride into the burned area
- B. Irrigate the area with neutralizing solutions
- C. Flush the exposed area with large amounts of water
- D. Apply lanolin ointment to the area
Answer: C
Explanation:
(A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury.
NEW QUESTION # 525
Which of the following blood gas parameters primarily reflects respiratory function?
- A. HCO3
- B. CO2 content of the blood
- C. PCO2
- D. Base excess
Answer: C
Explanation:
Explanation
(A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function.
(B) CO2 content of the blood is an indirect measure of respiratory function. (C) HCO3 is a measure of kidney function only and is important in acid-base balance. (D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.
NEW QUESTION # 526
The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Obtain arterial blood gases
- B. Remove the postoperative dressing to check for bleeding
- C. Encourage coughing and deep breathing each hour
- D. Increase O2 from 2-3 L/min
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.
NEW QUESTION # 527
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