Multiple Choice Single Response Item

NEXT GENERATION NCLEX Question Types Multiple Choice Single Response Item

These questions will be similar to the old format; however, the clinical scenario will be longer. Often, the clinical scenario will be part of a medical record. Also, the number of choices will not be limited to 4. There may be as many as 10 choices.

Let’s look at a sample question.

Multiple Choice Single Response Item

1 / 1

A 65-year-old client with COPD is admitted to the Emergency Department with a respiratory rate of 28, irregular pulse of 135 bpm, skin pale, cool to touch, & CFT = 4 seconds. The client is restless and oriented only to self. Wife and daughter at the bedside report that the client has been increasingly restless and confused since yesterday morning. Oxygen saturation 88% on room air.

Doctor’s orders include: Oxygen to keep saturations > 90%, diet as tolerated, chest x-ray, and arterial blood gas.

Based on this information provided, what should the nurse do First?

A) Draw the arterial blood gas stat to assess for impending respiratory failure.

B) Discuss with the family whether the client has had a similar episode before.

C) Elevate the Head of the Bed and Start oxygen

D) Begin clear sips of liquids. Hydration is important to improve tissue perfusion

E) Notify the physician of the client's current vital signs.

F) Listen to the client's lungs.

Intervention	Improves condition NOW	Helpful but not a NOW improvement
ABG		X(Will tell us if client needs intubation, but results take a while)
Discuss with family		X
Elevate HOB and Give Oxygen	X (Improves oxygenation immediately)
Sips of liquids		X (Oh wow, Really?)
Notify Physician		X(Rarely notifying physician makes clients better NOW unless you need orders or the client needs surgery)
Listen to client's lungs		X (Sit up the client and then listen to lungs)

Your score is

Here is a small list of famous priorities that will help you with "FIRST ACTIONS"

Air embolism

Place client in left Trendelenberg.

Lower Head and Elevate legs

Autonomic Dysreflexia

Sit up in bed to decrease blood pressure. Check for bladder distension or fecal impaction. Remove any noxious stimuli

Myocardial Infarction

Oxygen and Morphine always show up as choices. But you may also see nitroglycerin and aspirin
Goal: Treat chest pain. Chest pain = myocardial ischemia/infarct

If a client is on lasix

Assess for signs and symptoms of hypokalemia (muscle weakness) and check potassium levels.

If a client is on digoxin and lasix

Check potassium levels and digoxin levels.
Hypokalemia potentiates digoxin toxicity. If a client has visual disturbances (e.g., seeing halos) and hyperactive GI symptoms (diarrhea) always think digoxin toxicity.
Normal digoxin level is 0.8- 2.0 ng/mL

Syndrome of Inappropriate Diuretic Hormone

Too much antidiuretic hormone. Patient retains fluid. Patient is hyponatremic (dilution from too much fluid). Priority is to restrict fluid and monitor weight (best indicator of fluid retention/fluid status).

Monitor Neurological status (hyponatremia).

Bradycardias and Heart blocks

Have the external/transcutaneous pacemaker at the bedside

IV drug reaction/ Blood transfusion reaction

Priority is to stop the infusion.

The priority to report to PCP on clients taking prednisone, aspirin, heparin, levonox

Report black-colored stools= GI bleeding. Or any s/s of bleeding

Guillain Barre syndrome

Priority is to check breathing. Remember that paralysis/weakness starts from the lower extremities and moves up the body. The client will go into respiratory arrest/distress as the breathing muscles become weaker/paralyzed.

Client with diabetes complains of diplopia and headache

Check Blood sugar

Client with respiratory acidosis (e.g. pH 7.25 pCO2 68

Get intubation tray. Any patient in respiratory distress, get ready to intubate is almost always the answer.

Clients with acute renal failure

Watch for nephrotoxic drugs/antibiotics/Contrast dye
Watch for electrolyte imbalances, especially hyperkalemia (connect to monitor)

Thyroidectomy or parathyroidectomy

Have the tracheostomy tray at the bedside in case of airway closure due post operative edema/bleeding/hematoma
Check for hypocalcemia, even in thyroidectomies. The parathyroid may have been damaged during surgery.
Two important signs of hypocalcemia: Chvostek’s and Trousseau’s sign

Previous Lesson

Back to Lesson

Next Topic

NEXT GENERATION NCLEX

Multiple Choice Single Response Item

Single Response Question

Here is a small list of famous priorities that will help you with "FIRST ACTIONS"