The nurse notes the presence of a P wave, QRS complex, flattened T waves, and occasional U waves on a client's cardiac monitor screen. Fill in the correct missing information by choosing from the lists of options in the drop-down menus. - ANS-The nurse should suspect Your Answer: hypokalemiaCorrect...
NGN-NCLEX Prep Questions-Rationales
2023 Update
The nurse notes the presence of a P wave, QRS complex, flattened T waves, and
occasional U waves on a client's cardiac monitor screen. Fill in the correct missing
information by choosing from the lists of options in the drop-down menus. - ANS-The
nurse should suspect
Your Answer: hypokalemiaCorrect Answer: hypokalemia
because of the
Your Answer: flattened T waves and occasional U wavesCorrect Answer: flattened T
waves and occasional U waves
Rationale:Cardiac changes in hypokalemia include impaired repolarization, resulting in
a flattening of the T wave and eventually the emergence of a U wave. Therefore, the
nurse should suspect hypokalemia. The incidence of potentially lethal ventricular
dysrhythmias is increased in hypokalemia. The nurse should immediately assess the
client's vital signs and cardiac status for signs of hypokalemia. The nurse should also
check the client's most recent serum potassium level and then contact the primary
health care provider to report the findings and obtain prescriptions to treat the
hypokalemic state.
The nurse is preparing a client for a chest x-ray and notes that the client is wearing a
religious medal on a chain around the neck. What should the nurse do with regard to
this personal item? Click to highlight the correct answer from the options provided. -
ANS-The nurse should: (Select 1 option)
✓Ask the client if the chain and medal can be removed during the procedure.
Because: (Select 1 option)
✓The chain and medal may have cultural significance.
Rationale:Before certain diagnostic procedures, it is typical to have a client remove
personal objects that are worn on the body because of client safety and the possibility of
compromising test results. Therefore, the nurse should ask the client about the
significance of such an item and its removal because it may have cultural or spiritual
significance. If so, the nurse should ask the client if the item can be either removed
temporarily or placed on another part of the body during the procedure if appropriate.
While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: "I
have changed my mind. I don't want this surgery." Click to highlight the correct answer
from the options provided. - ANS-The nurse should: (Select 1 option)
Cancel the surgery.
Contact the surgeon.
✓Discuss the client's concerns.
Call the identified support person.
Because: (Select 1 option)
Client consent is required prior to any procedure.
,✓Further questions or concerns should be determined and addressed.
Ethical considerations are important for a client undergoing surgery.
The nursing scope of practice places limitations on how the nurse can respond.
Rationale:If the client indicates that he or she does not want a prescribed therapy,
treatment, or procedure such as surgery, the nurse should further investigate the client's
request. If the client indicates that he or she has changed his or her mind about surgery,
the nurse should assess the client and explore with the client his or her concerns about
not wanting the surgery. The nurse would then withhold further surgical preparation and
contact the surgeon to report the client's request so that the surgeon can discuss the
consequences of not having the surgery with the client. Further assessment and follow-
up related to the client's request need to be done. It is the client's right to refuse
treatment; however, further investigation is needed so the interventions can be tailored
to specific needs.
The nurse notes that there has been an increase in the number of intravenous (IV) site
infections that developed in the clients being cared for on the nursing unit. How should
the nurse proceed to implement a quality improvement program?For each action, click
to specify whether the action would be:
Indicated: an action that the nurse should take to resolve the problem
Non-essential: an action that the nurse could take without harming the client, but the
action would not be likely to address the problem
Contraindicated: an action that could harm the client and should not be taken - ANS-
Collect identifying patient information
Contraindicated
Note the mental status of the client
Non-essential
Note primary and secondary diagnoses of clients affected
Indicated
Note the type of IV catheter used
Indicated
Note the type of IV site dressings being used
Indicated
Note the medication types being infused
Non-essential
Note frequency of assessments of IV sites
Indicated
Note the expected duration of the IV site
Non-essential
Note care procedures to the IV site
Indicated
Note frequency of changing IV sites
Indicated
Rationale:Quality improvement, also known as performance improvement, focuses on
processes or systems that significantly contribute to client safety and effective client
, care outcomes; criteria are used to monitor outcomes of care and to determine the need
for change to improve the quality of care. If the nurse notes a particular problem, such
as an increase in the number of intravenous (IV) site infections, the nurse should collect
data about the problem. This should include information such as the primary and
secondary diagnoses of the clients developing the infection, the type of IV catheters
being used, the site of the catheter, IV site dressings being used, frequency of
assessment and methods of care to the IV site, and length of time that the IV catheter
was inserted. Once these data are collected and analyzed, the nurse should examine
evidence-based practice protocols to identify the best practices for care to IV sites to
prevent infection. These practices can then be implemented and followed by evaluation
of results based on the evidence-based practice protocols used. Collecting identifying
client information is contraindicated because of confidentiality and is unnecessary in this
quality improvement effort. Noting the mental status of the clients can be done but is not
likely to address the problem. Noting the types of medications being infused can also be
done, but will not address the problem of IV site infection. Although it is helpful to know
the expected duration of the IV site, this information does not change infection control
practices in managing the IV site and is therefore considered a non-essential action.
The nurse performs an Allen's test on a client scheduled for an arterial blood gas draw
from the radial artery. On release of pressure from the ulnar artery, color in the hand
returns after 20 seconds. How should the nurse interpret the finding? Fill in the correct
missing information by choosing from the lists of options in the drop-down menus. -
ANS-The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct Answer: The time for color
to return is prolonged
Rationale:Failure to determine the presence of adequate collateral circulation before
drawing an arterial blood gas specimen could result in severe ischemic injury to the
hand if damage to the radial artery occurs with arterial puncture. Upon release of
pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar
artery is insufficient, indicating that the radial artery should not be used for obtaining a
blood specimen. Another site needs to be selected for the arterial puncture, and the
primary health care provider needs to be notified of the finding.
The nurse has just received a client from the postanesthesia care unit (PACU) and is
monitoring the client's vital signs. Click to highlight the current finding(s) that would be
essential to follow up on. Highlight only finding(s) that require follow-up. To deselect a
finding, click the finding again. - ANS-30 min ago:
BP= 142/78
HR= 98
RR= 14
Temp= 37.2 C
O2 sat= 95% 3L NC
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