HW Qs, NCLEX-style

[StrawberryBanana]

Hello all~

I have some Qs that I finished and a few are really bugging me. They are not for credit, and I am not looking to copy, as I have researched and answered these..However, I'm still a little stuck on them, so I was looking for some more input. Perhaps you can take a look at one or two and see if you would choose the same answer as I did. I am using a book and study guide...and the study guide is horrible. I can't believe they even published it.

For anyone who wants to be RN study buddies, please feel free to add me. I love discussing topics of interest with other nurses and students.

------------------------Questions

A) The patient has a fever. Which of the following tasks would be appropriate to assign to the nursing assistant? Select all that apply.

1. Help the patient remove excess clothing.

2. Ask the patient about fever and chills.

3. Obtain an antipyretic from the medication room.

4. Take the temperature with an oral thermometer.

5. Talk to the patient about over-the-counter fever reducers.

6. Get the patient a popsicle.

I chose: 1,4,6. My study buddy chose #2, as well, but I'm debating this, as I thought that was more of an RN scope thing...and also, the Q confirms that we are aware that the patient has a fever, already.

B) The patient comes to the clinic for a physical examination and HIV testing. He tells the nurse that he thinks he may have been recently exposed to HIV. Which of the following assessment items should be included at this point? Select all that apply.

1. Sexual History

2. IV drug use

3. Current medications

4. Vital signs

5. Presence of anasarca

6. Change of mental status.

I chose 1 & 2. My buddy chose 1,2,4,6. The Q is confusing as I felt the last sentence was focusing on the HIV..but if not, I guess my buddy's answer would be right.

C) When performing a respiratory assessment, which of the following should be performed? Select all that apply.

1) Inquire about exposure to respiratory inhalants

2) Check the heart rate and rhythm

3) Auscultate the lungs bilaterally

4) Assess the temp. of the skin

5) Assess the color of mucous membranes

6) Assess the rate and quality of respirations

7) Check for the use of accessory muscles

8) Look for signs of anxiety or restlessness

I chose, 1, 2, 3, 6, 7, 8. My buddy doesn't think #4 should be included. My logic was due to the connection of temp. and circulation. Not sure if that makes sense.

D) Increasing fluid intake when the patient has chest congestion is helpful because: (select all that apply)

1. fluid helps decrease the cough reflex

2. coughing may cause dehydration

3. it helps thin secretions

4. it decreases the chance of infection

5. it may make secretions easier to cough up

6. it increases comfort of breathing.

I chose 3,5..but my study buddy thinks #6 is also one. I didn't think fluids ALWAYS made a difference in breathing ease..so I left it out.

E) The priority assessment for any patient with any problems of the upper airway is:

1. Anxiety and pain

2. Adequacy of oxygenation

3. Presence and thickness of nasal and oral secretions

4. Signs of dyspnea

I chose 1, just because I thought that anxiety and pain make it harder for a person to take in oxygen. Otherwise, I was thinking of choosing #2.

F) When administering respiratory medications to your patient, which one of the following would you administer last?

1. Albuterol

2. Montelukast

3. Robitussin cough syrup

4. Advair disc

My buddy and I are stuck between 3 & 4. I thought Advair was supposed to be rinsed out of your mouth, but absorb into your airways, etc. So I'm torn on the cough syrup, as well, as I thought it's supposed to coat your throat....

G)

During a seizure, it is important for the nurse to observe:

1. the type of aura the patient experiences

2. where movement occurs and how it progresses

3 the quality and rate of respirations during the seizure

4. the position of the patient's arms and legs during the seizure

I chose 1,but I also think 2 could be right. :-/ ?

H) The teaching plan for the patient with epilepsy should include:

1. refrain from drinking alcohol

2. do not go anyplace by yourself

3. do not become overly tired

4. wear Medic-alert bracelet or necklace

5. eat bananas to replace potassium loss

6. swim only with a partner.

I chose ALL of them..but not sure if I want to keep #2.

So what do you think? Ideas? I don't have answers in my book....but I'm just wondering what other people would choose.

[CoffeemateCNA]

A) It's not within the CNA's scope of practice to ask questions about fever and chills. He/she could certainly relay that information to you if the pt tells them about it, but you would need to go in and get that information yourself.

B) I would include current medications. Some medications may immunocompromise the pt.

C) Although in practice the heart and lungs will be assessed together, checking the HR and rhythm are technically part of the cardiovascular assessment. You will also want to check the mucous membranes as they can alert you to cyanosis (which of course indicates poor oxygenation).

F) I say give the Robitussin last. If you took the Advair last, you would still have to rinse it out of your mouth which may also rinse the Robitussin coating the oropharynx.

G) You're observing a seizure, so you are collecting objective information. The type of aura the patient experiences prior to a seizure is subjective. You would want to observe the movement and how it progresses.

[RNTutor, BSN, RN]

A) 1,4,6. These do not require the nursing process, so are appropriate for CNA (CNA's can take the temperature, but it is still the RNs job to interpret the temp, and the interpretation is the actual assessment). CNA asking about fever/chills would be an assessment, which is outside their scope.

B) I think this question is not great, because as you pointed out it is unclear if they want to know which specific assessments you would add because of HIV exposure, or if they want to know all the assessments you would do. I would suspect that the test writer would want you to know which assessments you would add, and I would only pick 1 and 2. But that is just me trying to read the test-writer's mind...

C) 1,3,6,7 are definitely right. I would not pick 5 because that falls under circulation. I am on the fence about 8, because it could be circulation, but it can also be a sign of decreased respirations. If I was taking an exam, though, I would not choose it though. Don't read into the question too much, if it says respiratory, just stick to respiratory. The other stuff is cardio assessment.

D) I would also pick 3,5. How would the fluid increase ease of breathing? I'm not sure I can think of a way right now, without reading into it too much anyway.

E) I actually would go with 3, and here's why: the question specifically asks about the upper airway. And that is the only answer choice that addresses the upper airway. Oxygenation and dyspnea tend to be more related to lower airway issues (problems at the alveoli). Anxiety and pain can affect airway, but not directly.

F) Robitussen last. You're supposed to avoid drinking anything for 30 min after taking it.

G) Whoa, I would say 3: AIRWAY. You want to make sure the pt is being adequately oxygenated during a seizure. Unless one of the options had something regarding safety (like make sure pt is on the floor, do not put anything in their mouth, protect their head), then I would pick airway.

H) Is potassium loss a big concern in epilepsy? it's not the first thing that comes to mind for me, but I don't know. I probably wouldn't have picked that one. But I would pick the others. Not sure if I would want to keep 2 either though, I would lean towards no because it seems a little extreme. I mean, can't they even sleep by themselves...?

[StrawberryBanana]

OMG Your answer for E really makes sense! Ugh, wish I would have thought of that. I'm always busy reading into questions and missed that. :-p

[RNTutor, BSN, RN]

OMG Your answer for E really makes sense! Ugh, wish I would have thought of that. I'm always busy reading into questions and missed that. :-p

Lol, it happens to the best of us!