NCLEX RN Review for Physiological Adaptation

1. A homeless individual is brought to the Emergency Room after having

been out in subfreezing temperatures for three to four days. The toes of the
patients right foot appear hard and cold with mottling, and are unresponsive
to touch. Which of the following would NOT be included in the initial
management of this patient by the Emergency Room nurse:
a. Rewarm the extremity with controlled and rapid rewarming until the
injured part flushes
b. Wrap the affected extremity in a blanket and apply moist heat
c. Place sterile gauze between the affected digits
d. Elevate the affected extremity
2. An elderly client has sustained an intertrochanteric fracture of the hip and
has just returned from surgery where a nailplate was inserted for internal
fixation. The client has been instructed that she should not flex her hip. The
best explanation of why this movement would be harmful is
a. Displacement can occur with flexion.
b. The soft tissue around the site will be damaged.
c. It will be very painful for the client.
d. It will pull the hip out of alignment.
ANSWER AND RATIONAL
1. B. This patient is suffering from frostbite, due to prolonged exposure to
sub-freezing temperatures without proper protection. Frostbite is a condition
in which there is trauma to the tissues without actual freezing of tissue
fluids. Exposed areas of the body such as hands, feet, earlobes, etc. are all
subject to this. The affected part becomes hard, cold, and is not sensitive to
touch, and mottled bluish-white in color. The aim of nursing care is to restore
normal temperature and circulation to the part. All other choices would be

included in the management of such a patient. Choice (2) is incorrect in

that wrapping of the part could further constrict circulation. If blankets are
used, it should be supported with a foot cradle and not in direct contact with
the extremity. Prolonged applications of heat should also be avoided due to
the patients diminished sensitivity, and could result in a burn if not carefully
monitored.
2. A. If the hip if flexed to the side, on the side of the bed or in a low chair,
hip displacment can occur. Displacement could result in pain, but this is not
the primary reason for the instructions. The remaining two answers are not
specific or adequate explanations.

NCLEX RN Review for Reduction of Risk Potential

1. A clients laboratory results have been returned and the creatinine level is
7 mg/dL. This finding would lead the nurse to place the highest priority on
assessing
a. Pupillary reflex.
b. Intake and output.
c. Capillary refill.
d. Temperature.

2. A client requires that a bronchoscopy procedure be done. Due to his

physical condition, he will be awake during the procedure. As part of the
pretest teaching, the nurse will instruct him that before the scope insertion,
his neck will be positioned so that it is
a. In an extended position.

b. In a neutral position.
c. In a flexed position.
d. Hyperextended.

ANSWER AND RATIONAL

1. B. The elevated creatinine level suggests impaired renal function.
Assessing intake and output will provide data related to renal function. The
other assessments are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and
allows the scope to be inserted without trauma.