Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 14

1. Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

A) Increased PaCO2
B) Decreased PaO2
C) Increased HCO3
D) Decreased base excess

2. Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?

A) Ventilation-perfusion (V./Q.) mismatch
B) Hypoxemia and respiratory acidosis
C) Mediastinal tissue and organ shifting
D) Decreased tidal volume and tachypnea

3. Hematotympanum and otorrhea are associated with which of the following head injuries?

A) Basilar skull fracture
B) Subdural hematoma
C) Epidural hematoma
D) Frontal lobe fracture

4. A client with a C-3 - 4 fracture has just arrived in the emergency room. The primary nursing intervention is:

A) Stabilization of the cervical spine
B) Airway assessment and stabilization
C) Confirmation of spinal cord injury
D) Normalization of intravascular volume

5. In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:

A) Auscultating bilateral breath sounds
B) Palpating for presence of crepitus
C) Palpating for trachial deviation
D) Auscultating heart sounds

1. Right Answer: C
Explanation: (A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.

2. Right Answer: C
Explanation: (A, B, D) These occur in both tension pneumothorax and open pneumothorax. (C) The tension pneumothorax acts like a one- way valve so that the pneumothorax increases with each breath. Eventually, it occupies enough space to shift mediastinal tissue toward the unaffected side away from the midline. Tracheal deviation, movement of point of maximum impulse, and decreased cardiac output will occur. The other three options will occur in both types of pneumothorax.

3. Right Answer: A
Explanation: (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.

4. Right Answer: B
Explanation: (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.

5. Right Answer: C
Explanation: (A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the hearts point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.

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