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 patient’s 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

patient’s 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 client’s 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.