Physiological Adaptation

Note: These questions include ones similar to alternative format questions as seen on the NCLEX-RN exam.

A 16-year-old sexually active female patient with a history of pelvic inflammatory disease (PID) presents to the emergency room with complaints of sudden right-sided lower abdominal pain and gastrointestinal distress. She cannot recall the date of her last menstrual period, but states she knows that she’s “late.” Her exam demonstrates a unilateral, right adnexal mass. The nurse knows that this patient likely has which of these prenatal complications?

A nurse is on-call after hours for a pediatric clinic. A parent calls and states that her 1-year-old child has a fever of 104ºF. She asks the nurse what can she do until she can bring the child in for evaluation in the morning. Which of these recommendations is incorrect for this patient?

When considering the source of a postoperative fever, the nurse knows that which of these is usually not a likely source?

Among these disorders, identify the one that is improperly matched with the electrolyte imbalance.

A nurse is caring for a patient with severe renal impairment. The patient has an intravenous catheter and is receiving fluids per the physician’s order. On a routine check, the nurse notes the patient is dyspneic, and the patient states that he feels short of breath. The nurse suspects fluid overload. Which of these other physical findings would help to confirm the nurse’s suspicion?

A 35-year-old male is brought to the emergency room by his wife. She states that he’s had the “stomach flu” for the past 2 days with severe diarrhea and vomiting. During the interview, the patient tells the nurse that he’s weak and fatigued. He also complains of lightheadedness, muscle spasms, as well as numbness and tingling in his extremities. The nurse is the first to review the laboratories ordered by the practitioner. Based on the patient’s history and symptoms, which of these results should the nurse report immediately to the ordering practitioner?

A nurse is working on the telemetry unit when one of her patients suddenly exhibits Torsades de Pointes. The nurse knows that which of these is true about this arrhythmia?

The nurse is assessing the electrocardiogram (EKG) reading of an elderly woman who has presented to the urgent care clinic with complaints of chest tightness, dyspnea, fatigue, and “fluttering” in her chest. The nurse should identify this rhythm (shown in the attached visual) as which of these?

A nurse is working in an indigent health clinic and has been asked to counsel and educate a patient undergoing treatment for latent tuberculosis infection with isoniazid for 9 months. Which of these is correct information for the nurse to give this patient regarding his disease and treatment?

A nurse is caring for a patient with dilated cardiomyopathy who is hospitalized for an acute flare of congestive heart failure (CHF). The patient has symptoms of fatigue, weakness, and dyspnea. The nurse notes peripheral edema as well as coolness and pallor in the distal extremities. Given this patient’s physiologic status, which of the following nursing interventions would be indicated? Select all that apply.

A. Teach and encourage the patient to perform appropriate light exercise interspersed with frequent rest periods.
B. Teach and encourage the patient to perform coughing, deep breathing, and incentive spirometry exercises.
C. Provide appropriate analgesia for occurrences of chest pain and give supplemental oxygen as indicated per the practitioner’s orders.
D. Take proper precautions to protect the patient from falls and injuries during transfers and ambulation.
E. Elevate the lower extremities to reduce peripheral edema and improve circulation with the use of sequential devices of TED hose.

A nurse is caring for a patient who just had an arterial line surgically placed in the femoral artery. Preoperative vitals showed a normal heart rate and blood pressure. The nurse knows that if the patient were to suffer the unexpected complication of an inadvertent puncture of the artery, she would most likely see which of these changes in this patient’s vital signs?

A nurse is educating a female patient on her recent diagnosis of chronic obstructive pulmonary disease (COPD). Which of these patient statements shows that she needs further education about her disease?

A 72-year-old female is admitted to the hospital for community-acquired pneumonia. At the time of admission, she is dehydrated, hypotensive, complains of weakness, and has a productive cough with thick, green sputum. She has a history of diverticulosis, but is otherwise healthy. She is started on a course of IV levofloxacin and on day 4 of treatment, begins to have diarrhea. The nurse knows that which of these places this patient at the greatest risk of Clostridium difficile (C. diff) infection?

The nurse has been ordered to perform gastric lavage on a patient. The nurse knows that which of these statements is correct regarding gastric lavage?

A 23-year-old male presents to the emergency department with complaints of progressively worsening abdominal pain and nausea over the past 12 hours. The nurse takes his vital signs and notes that he has a fever. The abdomen examination reveals a somewhat rigid abdomen with guarding and extreme tenderness in the right lower quadrant midway between the umbilicus and the superior iliac spine. Normal bowel sounds are present. Based on this history and presentation, which of these medical emergencies should the nurse suspect?

Which of the following statements are correct concerning the medical emergency of retinal detachment?
Select all that apply.

A. Without emergent ophthalmic evaluation, surgical intervention, and correction, permanent and total blindness may result.
B. Immediate interventions include placing the patient in a supine position with the head turned toward the side of the affected eye.
C. Patient history includes a sudden, painful, and complete loss of vision.
D. Retinal detachments may occur either spontaneously or following trauma.
E. The elderly, greater than 85 years of age, are at the highest risk for retinal detachment.

A 52-year-old male with type II diabetes has blood pressure readings between 125/84 and 134/92 mm Hg. His urinalysis shows no abnormalities. He is prescribed an ACE inhibitor. Based on what the nurse knows about this class of medications, which of these would be an abnormality found on his serum chemistry as a result of being on this medication?

Which of these is not considered one of the six stages of viral growth?

An 82-year-old patient with advanced Alzheimer disease is brought in by his daughter for a concern about a new medication. She states that since he started taking Haldol for increasing psychotic behavior, he has began having bizarre movements. The nurse knows that this drug can cause which of these behaviors?

A patient admitted to the hospital with an idiopathic spontaneous pneumothorax was successfully treated with a tube thoracostomy. The nurse is preparing him for discharge. He asks what the likelihood is that he will have this problem again. What is the most accurate response that the nurse should give this patient?