Health Assessment NCLEX Questions I

Health Assessment NCLEX Questions I 1. The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a Pco2 of 30mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? 1. A sodium level of 145 mEq/L 2. A potassium level of 3.2 mEq/L 3. A magnesium level of 2.4 mg/dL 4. A phosphorus level of 4.0 mg/dL 2. The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid–base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 3. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid–base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 4. A client has the following laboratory values: a pH of 7.55, an HCO3 – level of 22mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take? 1. Perform Allen’s test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing. 5. The clinic nurse is assisting to perform a focused data collection process on a client who is com- plaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client’s temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client’s respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease 6. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to note documented in the health record when collecting data related to the respiratory system for this client? 1. Stridor 2. Wheezes 3. Diminished 4. Pleural friction rub 7. The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss? 1.A defect in the cochlea 2.A defect in the 8th cranial nerve 3.A physical obstruction to the transmission of sound waves 4.A defect in the sensory fibers that lead to the cerebral cortex 8. The nurse is preparing to assist the health care provider to test the extraocular movements in a client for muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done to assess for muscle weakness in the eye? 1. Testing sensory function 2. Testing the corneal reflexes 3. Testing the six cardinal positions of gaze 4. Testing visual acuity using a Snellen eye chart 9. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds 10. The intravenous prescription is 1000mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number. Answer: _____ gtts/minute 1. 2 Rationale: Signs/symptoms of respiratory alkalosis include tachypnea, mental status changes, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results. Test-Taking Strategy: Recalling the clinical manifestations of respiratory alkalosis and the normal laboratory values will as- sist you with answering this question. Eliminate options that are comparable or alike in that they reflect normal laboratory values. You can then determine that the only abnormal labora- tory value is the potassium level. Review: signs/symptoms of respiratory alkalosis. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills: Acid–Base Priority Concepts: Acid–Base Balance, Clinical Judgment 2. 3 Rationale: Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in nor- mal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by COPD. Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory dis- ease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD. Test-Taking Strategy: Focus on the subject, chronic obstructive pulmonary disease, to assist with guiding you to select a respiratory acid–base balance. Then remembering that primary defects in the function of the lungs result in respiratory acidosis will direct you to the correct option. Review: causes of respiratory acidosis. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills: Acid–Base Priority Concepts: Acid–Base Balance, Clinical Judgment Reference(s): deWit, Kumagai (2013), p. 48. 3. 2 Rationale: The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition due to the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and respiratory alkalosis—can be easily eliminated. Test-Taking Strategy: Focus on the subject, nasogastric tube to low suction. Remember that hydrochloric acid is lost when the client is receiving nasogastric suctioning. This will direct you to the options that identify an alkalotic condition. Because the question addresses a situation other than a respiratory one, the acid–base disorder would be a metabolic condition. Review: causes of metabolic alkalosis. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills: Acid–Base Priority Concepts: Acid–Base Balance, Elimination Reference(s): deWit, Kumagai (2013), p. 47. Lewis et al (2014), p. 304. 4. 4 Rationale: The client is in respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a re- breathing mask as prescribed. Performing Allen’s test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis. Test-Taking Strategy: First determine the laboratory results. Because the pH is high and the Pco2 level is low, a respiratory problem is occurring. Then, applying the ABCs—airway, breathing, and circulation—you can determine that only one intervention deals with respirations. Review: the interventions for respiratory alkalosis. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills: Acid–Base Priority Concepts: Acid–Base Balance, Clinical Judgment Reference(s): deWit, Kumagai (2013), pp. 47–49. 5. 1, 2, 4 Rationale: A focused data collection process focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection in- cludes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client’s complaints. A musculoskeletal and neurological ex- amination also is not related to this client’s complaints. However, strength of peripheral pulses and a musculoskeletal and neuro- logical examination would be included in a complete data col- lection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment. Test-Taking Strategy: Focus on the data in the question. Noting the subject, how the client’s symptoms relate to the respiratory system, and the presence of an infection will direct you to options 1, 2, and 4. Review: the types of health and physical assessments. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages: Health Assessment/ Physical Exam Priority Concepts: Health Promotion, Infection Reference(s): deWit, Kumagai (2013), p. 20. 6. 2 Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or nar- rowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often sig- nals a life-threatening emergency. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces). Test-Taking Strategy: Focus on the subject, asthma and ad- ventitious breath sounds. Think about the pathophysiology that occurs in this disorder. Recalling that bronchial con- striction occurs will assist in directing you to option 2. Also, thinking about the definition of each adventitious lung sound identified in the choices will direct you to the correct option. Review: the characteristics of adventitious breath sounds. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages: Health Assessment/ Physical Exam Priority Concepts: Gas Exchange, Health Promotion Reference(s): deWit, Kumagai (2013), pp. 305– 306. 7. 3 Rationale: A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex. Test-Taking Strategy: Focus on the subject, a conductive hearing loss. Noting the relationship of the word conductive in the question and transmission in option 3 will direct you to this option. Review: the causes of a conductive and a sensorineural hearing loss . Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages: Health Assessment/ Physical Exam Priority Concepts: Health Promotion, Sensory Perception Reference(s): deWit, Kumagai (2013), p. 581. 8. 3 Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart checks visual acuity and Cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes check Cranial nerve V (trigeminal). Test-Taking Strategy: Focus on the subject, checking for muscle weakness in the eyes. Note the relationship between the words extraocular movements in the question and positions of gaze in the correct option. Review: the physical assessment technique for checking for muscle weakness in the eyes. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Developmental Stages: Health Assessment/ Physical Exam Priority Concepts: Health Promotion, Sensory Perception Reference(s): deWit, Kumagai (2013), p. 487; Ignatavicius, Workman (2013), p. 1047. 9. 2 Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema. Test-Taking Strategy: Focus on the subject, breath sounds in a client with pulmonary edema. Recall that fluid produces sounds that are called crackles. This will assist in eliminating the incorrect options. Review: the signs/symptoms found in pulmonary edema. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health: Cardiovascular Priority Concepts: Gas Exchange, Perfusion Reference(s): deWit, Kumagai (2013), pp. 314, 431. 10. gtts min 15gtts * 1000ml * 1hr 1ml / 12hrs / 60min = 20.8, or 21gtts/min