more nclex questions! thanks!

  1. A temperature would have to be taken via the rectal route for a patient:
    a. who is a mouth breather
    b. with a history of vomiting
    c. with an intelligence of a 7 year old child
    d. who cannot tolerate a semi fowlers position

    When assessing for cyanosis in a dark skinned person the nurse should assess the
    a. sclerea of the eyes
    b.nail bed of the toes
    c. lining of the eye lids
    d. color of the lower legs

    The vital sign that would change first indicating that a postoperative patient had internal bleeding would be the:
    a. body temperature
    b. blood pressure
    c. pulse pressure
    d. heart rate
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  2. 11 Comments

  3. by   KatieBell
    These questions are far simpler than what is seen on nclex. I would suggest that you use Saunders- as it will allow you to also look up the answers and rationales.
  4. by   Kns124
    okay thank you!
  5. by   steelcityrn
    im guessing A -- C --- C
  6. by   Goldenhare
    A, C, B---On the last one, I think B because as the pt is bleeding, there is less blood and therefore less pressure on the vascular structures. However, the pulse can stay the same at least for a while, then will speed up to compensate for the blood loss. Whadya think?
  7. by   Little Panda RN
    I believe A,C and I wonder if the last one is D. I say this because the heart rate seems to be one of the first indicators of shock. I would think that a person who is bleeding internaly would exhibit Tachycardia and severe hypotension. I could be very wrong (think I might just have to look this one up).
  8. by   cindyRN 2006
    I would say none of the answers in the first question are correct, You do not want to check temp. rectally unless you absolutely have to due to the risk of perforating the bowel. Of the answers listed I would go with A but then agian I would still not go the rectal route I would take tympanic or axillary. #2 the question is essentially asking you about if the patient is perfusing and a cood indicator of perfusion is cap refill. The last question the answer is the increased pulse. Why? because there is less BP so the heart is trying to compensate so it speeds up tachycardia is almost alway your first indicator of shcok and BP is a late S/S of shock. Hope it helps. I would also check the date on your NCLEX book the questions seem a little out of date with the rectal question.
  9. by   Nellie2B
    i take A , c, B(bp will be up). sorry if i am wrong
  10. by   Goldenhare
    Quote from cindyRN 2006
    I would say none of the answers in the first question are correct, You do not want to check temp. rectally unless you absolutely have to due to the risk of perforating the bowel.
    This is true! Maybe you do have an old book!

    The next one is somewhat debatable (my opinion) but here is what "Medical-Surgical Nursing", 6th edition, 2000, by Lewis, Heitkemper, Dirkson says......(forgive me APA fans!) says about #2 and #3

    #2-Cyanosis-in dark skinned individuals "Ashen or gray color most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds"--pg 483

    #3-"Stages of Shock--Initial Stage--decreased tissue perfusion-this stage is not be clinically apparent. Compensatory Stage--One of the first clinical signs of shock may be a fall in BP, which occurs as a result of a decrease in cardiac output."--pgs 1805-1806. The book goes on (and on and on...) to explain that next, the SNS simulates vasoconstriction to the most essential vital organs. Then in order, S&S are increase in venous return, increase in BP, slowing of peristalsis, cool and clammy, decrease in arterial oxygen, increase in respirations, THEN increase in heart rate. Hope this helps! Anyone got anything different?
  11. by   cindyRN 2006
    burke,k.m., lemone p., mohn-brown e.l. (2003)medical surgical nursing care connor, m.(ed) unit10 caring for clients expieriencing shock, trauma or critical illness pg. 201. upper saddle river, nj. prentice hall.
    my 2003 reference says in regard specifically to hypovolemic shock. that in the compensated stage(early stage) bp is normal to slightly decreased, in the progressive stage it becomes < 90mm hg and then becomes unobtainable in the irreversable stage. in regards to the pulse rate in the compensated stage it is >100 bpm (tachycardic) in the progressive stage it moves to >150 bpm (tachycardic) and irregular and at the irreversable stage it becomes slow and irregular.
    so i stand by my original answer tachycardia is the early sign of hypovolemic shock while decrease in bp is a late sign not even occuring until the progressive stage.
    when the body is vaso constricting like in your answer then the heart ( a very smart organ) tries to compensate and this is when you have the tachy cardia.
    Last edit by cindyRN 2006 on Nov 14, '05
  12. by   suzanne4
    I hate to break up a good thing here, but please be aware that we do need to follow US Copyright laws. This means that if the question has been taken directly from a book in its entirety and with all of the answer choices, and you do not have permission from the author or publisher, you are breaking the law.

    And please be aware that any questions that are directly from an NCLEX exam are completely verbotten by the Board that wrote the exam, and they have closed down other bulletin boards over this, as well as sued the posters. These things are not taken lightly by them.
  13. by   cindyRN 2006
    Thank You I did not know that.
    Last edit by cindyRN 2006 on Nov 15, '05

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