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NCLEX-RN Exam Questions - Part 59
1. A newborn has been delivered with a meningomyelocele. The nursery nurse should position the newborn:
A) Prone
B) Supine
C) Side lying
D) Semi-Fowler
2. Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A) Cover sac with dry sterile dressing
B) Cover sac with saline-soaked sterile dressing
C) Do not apply dressing; keep sac open to air
D) Aspirate any fluid from sac
3. A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Metabolic acidosis
4. A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28,PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Metabolic acidosis
5. A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.What tests should the nurse anticipate?
A) Reticulocyte count, creatinine phosphokinase (CPK)
B) Aspartate transaminase, alanine transaminase
C) Sedimentation rate, WBC count
D) Lactic dehydrogenase, CPK
A) Prone
B) Supine
C) Side lying
D) Semi-Fowler
2. Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
A) Cover sac with dry sterile dressing
B) Cover sac with saline-soaked sterile dressing
C) Do not apply dressing; keep sac open to air
D) Aspirate any fluid from sac
3. A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Metabolic acidosis
4. A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28,PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Metabolic acidosis
5. A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.What tests should the nurse anticipate?
A) Reticulocyte count, creatinine phosphokinase (CPK)
B) Aspartate transaminase, alanine transaminase
C) Sedimentation rate, WBC count
D) Lactic dehydrogenase, CPK
1. Right Answer: A
Explanation: (A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to prevent trauma and infection of the sac. (B) The supine position exerts pressure on the sac. (C) Newborns usually cannot maintain side-lying position. (D) The semi- Fowler position exerts pressure on the sac.
2. Right Answer: B
Explanation: (A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.
3. Right Answer: D
Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.
4. Right Answer: B
Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.
5. Right Answer: D
Explanation: (A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury.(C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
Explanation: (A) The prone position reduces pressure and tension on the sac. Primary nursing goals are to prevent trauma and infection of the sac. (B) The supine position exerts pressure on the sac. (C) Newborns usually cannot maintain side-lying position. (D) The semi- Fowler position exerts pressure on the sac.
2. Right Answer: B
Explanation: (A) A dry, sterile dressing would adhere to the sac, causing tissue damage. (B) A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying. (C) A sac open to air causes drying and potential for contamination. (D) This intervention is not an independent nursing action.
3. Right Answer: D
Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3.(D) Metabolic acidosis is determined by low pH and HCO3.
4. Right Answer: B
Explanation: (A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.
5. Right Answer: D
Explanation: (A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury.(C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
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