[ANSWERS & RATIONALE] NCLEX PREP Reduction of Risk Potential

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1. D. These test results indicate anemia. Impaired oxygen-carrying capacity of red blood cells causes cellular hypoxia and results in fatigue. Conserving energy limits oxygen expenditure and minimizes fatigue. Increased mobility (4) increases the demand for oxygen and contributes to fatigue. Although hypoxic tissues are more vulnerable to breakdown, protecting the integumentary system (1) is not as high a priority as is the promotion of the body’s overall oxygenation. Constipation (3) is not a problem in anemia.

2. D. The first specimen is discarded because it is considered “old urine” or urine that was in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.

3. D. While all the other conditions may be complications, bleeding from the site is the main concern. The procedure is done to achieve relief from infection caused by urinary stasis, which may have resulted in kidney congestion.

4. B. Glycosylated Hemoglobin (Hgb) is a lab value which reflects glucose combining with Hgb and attaching to the red blood cells (RBC’s) for the life of RBC.  This test, therefore, is indicative of control of blood sugar, regardless of increase or decreases in serum glucose values. A value of 10% or less is considered good control.  Choices (1) and (3) are incorrect, although (4) might seem likely and may be true, it is NOT correct in this instance.

5. B. Demand Pacemakers will fire ONLY when the heart’s spontaneous beat falls below the minimum rate.  Electrodes for sensing and pacing are placed in the ventricles. Choice (1) refers to an Asynchronic Pacemaker which is unaffected by heart regular beat; Choice (3) refers to Synchronous and A-V Sequential type Pacemakers, however, it is the sensing electrode ONLY and both sensing and pacing electrodes are placed in the atria in the A-V mode.  Choice (4), a Pacemaker may be a temporary modality, but can also be permanently implanted, making this choice incorrect.

6. A. Although BUN is a measure of kidney function, patients who are dehydrated (without kidney disease) can show an elevation in Blood Urea Nitrogen (BUN).  Creatinine is a specific indicator of renal function and/or failure.

7. B. The presence of dark brown “coffee ground” drainage may indicate the presence of bleeding or blood in the GI tract.  Because this maybe the case the nurse should FIRST perform a Hemoccult Test to determine this.  Choice (1) checking the pH will only help to determine gastric acidity; Choice (3) and (4) would not be correct nursing actions in this case.

8. D. Maintaining an ICP of less than 20mmHg, and a CPP (Cerebral Perfusion Pressure), usually at least 60mmHG, or as ordered are considered to be within normal limits.  Intracranial Pressure monitoring is done through the placement of a catheter in the ventricle of the brain.  Normal ventricular pressure is 10mmHg.  Pressures of 11-20mmHg are considered to be mildly elevated, and pressure above 20mmg is to be high, and a definitive sign of increased ICP.

9. C. Elevated AFP may indicate a neural tube defect.

10. C. This position in the immediate post operative period allows for constant observation of the airway and prevention of injury to the suture line.  Options 1, 2 and 4 will risk injury to the suture line.

11. D. In the post-op period following an amputation of a lower extremity, nursing interventions are aimed at preventing deformities, building and maintaining muscle strength, and mobilizing patient’s joints.  Placing the patient in the prone position twice daily is specifically aimed at stretching the flexor muscles, and preventing flexion contractures of the hip.  The other choices (1), (2) and (3), are also important parts of the nursing care, but do not answer the question.

12. B. Choice 2 is the normal post partum fundus, at two hours, regardless of mode of delivery.

13. C. Uteroplacental insufficiency reduces 02 to the fetus and causes fetal hypoxemia

14. C. This is the correct positioning of Bryant’s traction, when a nurse observes an appropriate treatment the nursing action to be taken is to document the findings.

15. A. When removing a chest tube the physician will ask the patient to exhale and hold their breath, or exhale and bear down.  This will serve to increase intrathoracic pressure, as well as prevent air from entering the pleural space.

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