Fun NCLEX Scenario Quiz!

[steven007, BSN, MSN]

I did up a little scenario for fun! It's just five questions but I think they're very good ones, if I do say so myself! =)

A nurse working in the ER is assigned to Mr. Bob, an 82 year old male patient who was admitted from his long term care facility with complaints of difficulty breathing. Upon inspection the nurse notes cyanosis of the lips and nail beds as well as severely clubbed nails. Vital signs are as follows: 143/82, 37.2 degrees celcius, respirations 30 and shallow, Sp02 65. He has a history of heart disease and had a heart attack 3 years ago.

The following questions pertain to the given scenario

1. What should be the initial nursing action for this patient?

a) Perform a respiratory assessment being sure to auscultate the lung sounds carefully

b) Administer IV salbutamol

c) Position the client sitting, with his head lowered between his legs

d) Administer O2 at 2L/min

2. The physician orders 60% oxygen in a low flow simple face mask. The nurse would:

a) Administer oxygen at 50% as this is the maximum for a simple face mask

b) Administer oxygen via nasal cannula as this has the same result and there is no SFM available

c) Question the physician's order as low flow masks are contraindicated for COPD patients

d) Check with the physician as simple face masks are contraindicated for CO2 retainers

3. Mr. Bob later becomes very confused and agitated and continues to remove his mask. He is unaware of his surroundings. Upon auscultation of his lungs the nurse hears crackles. Blood pressure is 210/118. What is the nurse's first response?

a) Notify the physician immediately

b) Change oxygen from 60% to 100%

c) Place patient in fowlers position, administer nitro and notify the physician

d) Obtain an immediate physician's order for nitroDUR and Lasix (furosemide)

4. Because the client is still confused and agitated, the nurse would except which drug to be prescribed by the physician?

a) Ramipril

b) Atenolol

c) Dopamine

d) Captopril

5. The nurse knows that the best oxygen delievery device for Mr. Bob would probably be

a) Nasal Cannula

b) Partialrebreather

c) Nonrebreather

d) Venturimask

Answers:

1. a) Incorrect: though a respiratory assessment is crucial, the physical appearance (cyanosis) of the client, the respiratory status (laboured breathing) and the SpO2 reading indicate that the patient needs oxygen STAT.

b) Anything IV requires a physician or nurse practitioners order

c) Incorrect, this is sometimes used for people feeling like they are going to faint as a first aid measure, but generally is accepted as not a very good position

d) Correct: the condition of the client permits for such an intervention

2. a) Incorrect, simple face masks can deliver a max of 60% O2

b)Incorrect, Nasal cannula has a max oxygen percentage of 44%

c) Low flow devices are not all contraindicated for COPD patients

d) Correct, simple face masks are contraindicated for CO2 retainers

3. a) You would definitely notify the physician, just it would not be the first thing you as a nurse do as this blood pressure is a hypertensive crisis and requires STAT medical intervention to prevent organ failure, so time is of the essence

b) At this point, oxygen isn't going to do you much good.

c) Correct! Using good judgement, if the nurse determines that there is no contraindication for nitro then she should administer it, again, this is a medical emergency that requires immediate intervention.

d) Lasix will probably be prescribed, but at this point the patient is very confused and agitated. The patient needs to be restricted of fluids and have his blood pressure brought back down before anything else. Immediate Lasix would have to be pushed via IV and IV is not a good idea when someone is agitated, confused and has prominent crackles with such a high blood pressure.

4. A) Unlikely

b) Unlikely

C) VERY unlikely

d) Yup. Captopril can be dipped in water and used sublingually which is good considering the patient is not in a position to swallow

5. A) nope

b) No

c) Nah

d) Yup.

[Double-Helix, BSN, RN]

Hi. Thanks for trying to write some practice questions. I have to ask where you got your rationales for these responses and answers?

Here's my critique:

Question 1. I agree with giving oxygen first. Although if I had a pt with a sat of 65, I'm going to start off higher than 2L/min. Your senario doesn't say anthing about the pt having COPD or CO2 retention, though the cubbed fingers indicate chronic oxygen deprivation. I also would do a thorough respiratory assessment. There are many causes of respiratory distress. An asthma attack and heart failure will both cause the symptoms you listed, but the lung sounds will tell you the difference. Of the options you provided though, O2 is the most accurate.

Question 2. Why are SFM contraindicated more than NC, NRB, or Venturi masks? I get that the pt retains CO2, but flow rate of 5L or greater on a SFM helps prevent rebreathing of CO2. Sure, if the patient doesn't need a mask they should not get it. But sometimes you don't have a choice. If the patient needs a higher flow than you can give through an NC, they are going on a face mask whether they retain CO2 or not.

Question 3. In the first question, you stated an answer was incorrect because you didn't have an order, but in this question, the correct answer involves the nurse giving a medication that requires an order too. So you should specify that the nitro is ordered.

Question 4. This patient is going to be getting IV medication, provided he has IV access. IV medications take effect much more quickly than sublingual. You said that IV meds aren't a good option for a confused, agitated patient? Why would sublingual be any better? Do you really want to be sticking a syringe of medication into a confused, agitated person's mouth? And then explain that they can't swollow the medication, but need to hold it under their tongue until it absorbs? Never going to happen. Captopril, along with Ramipril, is an ACE inhibitor, one of the first lines of treatment for HF. Captopril might be used, but not because it can be taken SL.

Question 5. Umm, is this really your rationale? The answer to this question also depends on a lot of other variables, such as what the patient is satting and how they respond to treatment.

[steven007, BSN, MSN]

1. In ontario, according to our regulatory body, if O2 is not administered and you absolutely see a need to administer it, you generally start off at 2 L and evaluate. Work up from 2L as a base point. Generally you start with NC, which can only go up to 6 L or 44% O2 saturation unless it’s an emergency where you have a SFM in which you would could get up to 60% O2. However, it remains the same, start at 2 and evaluate.

2. If you remember back to your clinical nursing courses, you would have learned the difference between Low flow vs High Flow devices. Low flow work with patient’s ventilation patterns and thus are generally not as useful as a high flow device such as a ventrui which can more effectively regulate the breathing patterns of a patient in respiratory distress.

3. I’m sorry, I kind of really seem to have neglected the difference in nursing regulation. Under the nurses judgement, in an ER or ICU setting something like nitro doesn’t necessarily have to be ordered for a nurse to use it in an emergency. Rationale for that is why have a nurse in a hospital where you admit critical patients if she can’t do anything?

4. No, not all patients are on IV. You’re right in the sense that I should’ve specified that he didn’t have an IV going, but if he did then you would want to notify the physician to have it stopped as an IV line infusing with his status is really not a good idea, unless you want to drown your patient in their own secretions, which is apparently acceptable to most nurses today because it was lousy nursing care that allowed my grandmother to drown in her own secretions. They were infusing 100 ml/hr of IV fluids into her while she had awful lung crackle, low O2 sat and was coughing up phlegm like there was no tomorrow and no nurse would do anything about it. So it’s not surprising to see nurses quick to go pro-IV, but it’s wrong.

5. Yes, you are right. And again I should’ve specified more but as a general rule Ventrui masks are preferred for low sat, COPD patients. From personal experience in ICU I find ventrui has been more effective in congestive heart failure patients who are agitated than anything else.

Thanks for your feedback, I didn’t realize I forgot these details!! But it was fun to make at least =).

[caliotter3]

Looks like you're taking this seriously! Good work!