CRITICAL THINKING NCLEX RN 2018
NCLEX RN Emergencies / SEE FIRST/ Unexpected / PRIORITY --
ALL IMPORTANT notes
Prepared by kachozom RN- www.kachozom@blogspot.com
= Think=
1-A client with spinal injury at Cervical =breathing problem/risk for pneumonia
-A client with a spinal cord injury at Thoracic =risk for pneumonia/ bowel
-A client with a spinal cord injury at lumbar = risk for urinary incontinence/ autonomic dysreflexia. |
symptoms of acute gastritis or ruptured esophageal varices related to excessive alcohol intake and is at risk for hypovolemic shock and aspiration of blood.
3-A post op client with abdominoperineal resection, reports chills =
he is at risk for developing peritonitis because chills may indicate infection
4-A client is vomiting and has frothy oral secretions =
this could indicate a tracheoesophageal fistula and potentially cause aspiration.
5-The client with an oxygen saturation of 79% on room air =
as the oxygen saturation is low,assess pt & start o2..
6-A client with Chest pain, dyspnea, and hemoptysis =
symptoms for a pulmonary embolism, a life-threatening complication.
7-A client with Worsening dyspnea and chest pain =
symptoms of pleurisy or inflammation of the pleural cavity
8-A cardiac client had fainting episode =
may be the result of an irregular cardiac rhythm or rate change, and requires an immediate cardiac evaluation to prevent cardiac and respiratory arrest.
9-A client receiving chemotherapy is afebrile but has a productive cough=
Might be ill because of bone marrow depression, needs intervention.
Might be ill because of bone marrow depression, needs intervention.
10-A client is pale and diaphoretic, who reports sudden and severe pain radiating from the flank to the scrotum =
Symptoms may be due to pyelonephritis or renal calculi,requires quick attention to diagnose, assess and manage the pain
Symptoms may be due to pyelonephritis or renal calculi,requires quick attention to diagnose, assess and manage the pain
11-An elderly client admitted four hours ago with status asthmaticus=
Life threatening condition which can last longer than 24 hours, constantly monitor client if unresponsive to bronchodilators
12-A red reflex is absent in the newborn's right eye =
absence of a red reflex indicates an ophthalmic emergency as light is not being transmitted to the retina, and early suppression of optic nerve function, which results in the obstruction of the light, can cause blindness.
13- A client who intentionally ingested 15 acetaminophen tablets prior to arrival =
requires activated charcoal and possible administration of acetylcysteine.
14- A old client who has had generalized weakness for the past few days =
requires assessment and diagnostic workup to exclude myocardial infarction, electrolyte imbalance, and stroke.
15-A multipara who delivered a 5-lb, 8-oz baby after three hours of labor =
Precipitous labor is a risk factor for early postpartum hemorrhage and also for amniotic fluid embolism.
Precipitous labor is a risk factor for early postpartum hemorrhage and also for amniotic fluid embolism.
16-A client saying the arm cast feels too tight =
too tight may indicate compartment syndrome assess current neurovascular status.
17-A client who reported nausea, general anxiety, and is diaphoretic =
Even though not complaining of chest pain, these symptoms should be treated as a potential MI, A cardiac workup should be performed immediately.
18-A client experiencing headache, fever, and neck stiffness =
Headache, fever and neck stiffness are s/s of meningitis, assess first.
19-Experiencing a tingling sensation in the face and arm =
Face and arm tingling could indicate a stroke
20-A client reporting chest heaviness =
Chest heaviness requires an immediate electrocardiogram and laboratory tests to rule in or rule out a myocardial infarction.
21-A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea =
It may indicate a possible bowel obstruction that can be life threatening if the bowel perforates, assess this client quickly.
22-A old aged client with hypertension reporting headache and
blurred vision =
These are symptoms of a hypertensive crisis, requires immediate intervention.
23-A 7-month old with vomiting and diarrhea =
risk for dehydration and electrolyte imbalances due to the small body mass, inability to compensate effectively, and loss from both upper and lower GI sources.
24-A client with a BP of 90/60 mmHg whose skin is hot and dry to touch =
It indicates dehydration caused by hyperglycemia,This is the first stage of diabetic ketoacidosis.
25-A Client who is unconscious with left sided tracheal shift from midline =
A left sided tracheal shift from the midline is the first sign of a tension pneumothorax. Airway and breathing are the priority.
26-A Client who clutches the chest and reports severe chest pain=
The client with chest pain is having a circulatory problem.
27- client receiving intraspinal anesthesia for pain control with a heart rate of 76 bpm and a respiratory rate of 8=
clients must be assess or closely monitored for signs of CNS depression
28-clients with crushing chest wounds are at risk for a number of injuries=
immediate evaluation is required for pneumothorax,keep HOB>30.
immediate evaluation is required for pneumothorax,keep HOB>30.
29-A child with burns on the face=
burns can be life-threatening to children; airway, breathing, and circulation are major concerns; cardiopulmonary complications may result from exposure to electrical current, inhalation of toxic fumes, hypovolemia, and shock
30-A patient diagnosed with hemophilia complaining of joint pain or sprain =
joint pain indicates bleeding; treatment includes factor VIII, RICE ( rest, ice, compression, and elevation)
31-A newborn experiencing projectile vomiting and irritability=
indicates pyloric stenosis; at risk for fluid and electrolyte imbalance
32-A restless client with pale, cool, clammy skin and a rigid abdomen with absent bowel sounds=
Assess the client,likely has injuries to abdominal organs, resulting in hemorrhage
33-An infant with failure to gain weight and a lead level of 70 ug/dL=
high risk for injury, requires immediate attention; provide medical treatment and chelation therapy, begin lead hazard control
34-An elderly client with a history of cardiomyopathy who aspirated
34-An elderly client with a history of cardiomyopathy who aspirated
=ensure that client has patent airway; at risk to develop pneumonia
35-An elderly client diagnosed with heart failure (HF) who has been vomiting=
assess this client,may have digitalis toxicity,check Digitalis level.
36-A client with a history of coronary artery disease (CAD) who complains of midepigastric pain radiating to the neck=
risk of myocardial infarction; pain that originates in the chest or abdomen and radiates to the neck, shoulder, or arm requires immediate evaluation
37-A client at 34 weeks’ gestation diagnosed with generalized edema and complaints of epigastric pain=
Edema and epigastric pain indicates pending eclampsia
38-A client complaining of lightheadedness; nurse notes client is clam, pulse 115, respirations 28=
Asses the client; appears to be developing shock
39-A client whose muscle tone of all four limbs is flaccid=
indicative of serious irreversible impairment,asses Neuromuscular
40-A child with a fever, headache,malaise, anorexia, and ear pain with chewing=
probably mumps; precautions first as child is communicable before assessing.
41-The "soft spot" on the head of a 4-day-old newborn feels slightly elevated when the baby sleeps=
The fontanel or the "soft spot" should feel soft and flat. Bulging or an elevation indicates an increase in intracranial pressure
42-A primigravida client with baseline fetal heart tones 137 bpm with decelerations to 114 bpm independent of contractions=
This describes repetitive variable decelerations, which indicates an umbilical cord occlusion that needs to be resolved;There is immediate risk to the safety of the fetus
43-Lactic acid level 5.0 mEq/L =
A normal lactic acid level is 0.5 to 2.2 mEq/L ,Elevated levels indicate inadequate oxygenation in the body or the presence of shock
44-A blood at a venipuncture site and around an intravenous catheter=
The bleeding is an indicator of disseminated intravascular coagulation (DIC);
a life-threatening problem.
45- A client pulse are strong and bounding and the respiratory rate is 26 bpm=
Strong bounding peripheral pulses occur in the early hyperdynamic stage of septic shock.
46.A client with sickle cell anemia is admitted to the hospital for a vaso-occlusive crisis=
IV and oral fluids are the primary treatment to reduce blood viscosity,next pain management and
then Nasal cannula 2L/min oxygen if needed.
then Nasal cannula 2L/min oxygen if needed.
47. A client complaint of a nagging cough that won’t go away=
A client diagnosed with asthma is at risk for upper respiratory disease and infection.
notify the HCP regarding symptoms of infection, including a cough.
notify the HCP regarding symptoms of infection, including a cough.
Caution if wheezing stops-sign of breathing obstruction.
48.A client with an abdominal abscess draining into a bulb suction device=
Assessing whether the drainage is purulent, sanguineous, serosanguineous, etc. the most important characteristic to document; Dark green or yellow drainage may indicate the client has not improved. Pale yellow serous drainage may indicate clearing of the infection.
49.A client had a sudden onset of decreased level of consciousness, blurred vision, headache, and slurred speech=
assessment for hypoglycemia, The client's symptoms also are suggestive of a possible TIA or CVA.
50.Post op Craniotomy, Urine output 5000 mL in 24 hours=
A head injury can cause DI ( diabetes insipidus.)
51-client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 and reports hunger, sweating, tachycardia=
signs of hypoglycemia , check blood sugar, give orange juice or carbs & recheck
52-A post op(CABG) client , the nurse discovers a client sitting in a chair; The client is cool & pale, and responds only to loud verbal stimuli=
The cool, pale client experiencing decreased levels of consciousness (LOC) needs to be reclining in bed to increase perfusion to the heart then cover with warm blanket.
53-The client with generalized weakness and dizziness and pulse 30 bpm=
this client should be triaged as critical due to the signs and symptoms of hypoperfusion
54-A solitary, flat, black plaque on the lower abdomen in infant=
A congenital melanocytic nevi requires follow up due to the potential for malignancy.
55.The client with confusion and blood glucose 42=
This client should be triaged as critical due to symptomatic hypoglycemia.
This client will progress to death without intervention
56.T-5 after a motor vehicle crash (MVC)=
Bladder retention will cause autonomic dysreflexia due to elevation in ICP. The nurse should immediately scan the client’s bladder and perform a catheterization to prevent this occurrence.
*T3 post spinal injury,-Warm, dry skin and skin flushing may be manifestations of neurogenic shock.
57.spinal cord injury at the level of L1 in a motor vehicle accident (MVA)=
Applying manual pressure to the bladder aids in emptying the bladder completely and helps reduce risk for infection. Performing the Credé maneuver every day can result in bladder control.
Applying manual pressure to the bladder aids in emptying the bladder completely and helps reduce risk for infection. Performing the Credé maneuver every day can result in bladder control.
58-Situation (in a cafe)Suddenly, a woman gasps for breath and grabs her throat. Which action does the nurse take first=
assess by asking the client to speak ,If the client can speak or cough, then it is a partial obstruction. If they are unable to speak or cough, then they are experiencing a total obstruction and the Heimlich maneuver should be used.
59-Aclient with blood glucose is 525,pH is 7.1, and serum bicarbonate level is 14 mEq/L and has ketonuria=
The lab results are indicative of diabetic ketoacidosis(metabolic acidosis)
*Don’t confuse with HHS, blood glucose is greater than 600 mg/dL
60-A nurse assessed a client with Rapid respirations=
tachypnea, a symptom of pneumothorax
tachypnea, a symptom of pneumothorax
*Sudden chest pain=signs of Pulmonary embolism
61- A nurse assess a client with Deep, rapid respirations(hyperpnea)=
Hyperpnea causes include metabolic acidosis and diabetic ketoacidosis.
*Hypercapnia= seen in COPD,Chronic Bronchitis, Emphysema( keep low oxygen)
62- A nurse assess a client with Respiratory depression=
This occurs with an overdose of narcotics or opioids,give antidote Naloxone
*tachypnea(shallow and rapid breaths)
63-A nurse observes a client in Periods of hyperpnea alternating with periods of apnea=
This describes Cheyne-Stokes respirations, which are caused by a cerebral lesion;seen in sleep apnea and comatose patient.
64-A Pre op client for a mastoidectomy due to chronic otitis media=
the client may be experiencing vertigo; ask first to ensure client safety.
65-Chest on the affected side is pulled inward during inspiration and bulges outward during expiration=
A flail chest is caused by fractures of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically.
66-A client with cervical cancer for the insertion of an internal radiation implant= keep bed rest and a Foley catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts..Bowel movements can dislodge the radium implant,keep on Low residue diet
68-A client is discharged from the emergency department after evaluation for a concussion with loss of consciousness=
allow them to rest for longer periods to prevent brain hyperexcitability. Avoid aspirin, as it can prolong any bleeding that might occur,Give Acetaminophen
69-A woman at 6 weeks’ gestation who complains of left lower quadrant abdominal pain and vaginal spotting.=
The symptoms of an ectopic pregnancy, may result in death
70-Reducing environmental stimuli is essential to reducing complications=
Meningeal irritation causes headache, light sensitivity, and seizures.
71-A client with AIDS, had a chest tube removed yesterday and reports crackling under his skin =
describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact health care provider
72-The right leg is shorter and outwardly rotated and adducted =
indicates hip fracture or dislocation of prosthesis;report to the HCP.
73-A client is unable to close eye voluntarily=
when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye,watch for corneal abrasion.
74-A client is restlessness and rapid, weak pulse, confusion=
=signs of Addisonian crisis;*(like signs of cardiogenic shock)
75-A postoperative cataract client is cautioned for=
sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure or put pressure on the suture line
76-cautions the client with hypothyroidism to avoid which implementation=
client is very sensitive to narcotics, barbiturates, and anesthetics
77-A client having severe allergic reaction after receiving a blood transfusion= stop the transfusion first; symptom is characterized by wheezing, urticaria (hives), facial flushing, and epiglottic edema
*circulatory overload; severe anaphylactic reaction may cause hypotension
77-A client having severe allergic reaction after receiving a blood transfusion= stop the transfusion first; symptom is characterized by wheezing, urticaria (hives), facial flushing, and epiglottic edema
*circulatory overload; severe anaphylactic reaction may cause hypotension
78-allergies to iodine or seafood must be reported immediately before=
a cardiac catheterization to avoid anaphylactic shock during the procedure
79-The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit =
insulin levels remain high while glucose levels decline; results in hypoglycemia.
*watch for Hyperglycemia when client is on TPN
80-The child is admitted with drooling and an inflamed epiglottis=
indicative of an increase in respiratory distress; early sign of hypoxia,
81-Caution for an IV pyelogram (IVP) client scheduled in 2 hours=
check for allergy for selfish, Metformin for DM, should discontinue 48 hours prior to procedure;*contrast media can cause life-threatening lactic acidosis
82-caution post scleral buckling procedure to repair a detached retina=
fixed and dilated pupil represents a neurological emergency, has symptoms of (ICP)
-do not use narcotics
-do not use narcotics
83-A child ingests some substance from kitchen=
Position left side lying to prevent aspiration, Call poison control
84-There is clear fluid draining from the infant’s right ear=indicates a rupture of meninges after sustaining a closed head injury
85-A client receives parenteral nutrition (PN),if the pulse rate increases=
may indicate fluid overload, if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume
86-A toddler playing with small toys and sudden appears distress and cannot speak0
= symptoms of choking, assess for aspiration of foreign body.
86-A toddler playing with small toys and sudden appears distress and cannot speak0
= symptoms of choking, assess for aspiration of foreign body.
87-a toddler with barking cough,infrequent instigators stridor=
symptoms of Croup( laryngotracheobronchitis)
symptoms of Croup( laryngotracheobronchitis)
88-client with asthma,who just received nebuliser albuterol,now appears to be resting after a sudden decrease in wheezing=
assess for silent chest or status asthmaticus
assess for silent chest or status asthmaticus
89- when you will can tell if she is having baby boy or girl=
Think about positive signs, it’s at 16 weeks.
90-when child should have MMR=
Think about live vacation and learn the immunisations.the child can MMR at 12 month and above.
-------------------------------Good luck with your NCLEX RN---------------------------------------------
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