Cloze (Drop-Down) NCLEX Practice Questions

The standard therapeutic INR for nonvalvular atrial fibrillation is 2.0 to 3.0, with a target of about 2.5. An INR of 1.0 to 2.0 is subtherapeutic and leaves the client at continued risk for cardioembolic stroke. The higher range of 2.5 to 3.5 is reserved for specific higher-risk indications such as a mechanical mitral valve or some cases of antiphospholipid syndrome, not for routine atrial fibrillation, and 3.0 to 4.5 exceeds any routine outpatient target and carries excessive bleeding risk.

Vitamin K (phytonadione) is the specific reversal agent for warfarin because warfarin works by inhibiting vitamin K epoxide reductase and depleting functional clotting factors II, VII, IX, and X. For major bleeding, current practice pairs intravenous vitamin K 5 to 10 mg with four-factor prothrombin complex concentrate, or fresh frozen plasma when PCC is unavailable. Protamine sulfate reverses heparin, not warfarin. Aminocaproic acid is an antifibrinolytic used for bleeding from fibrinolysis, not for vitamin K antagonist reversal. Calcium gluconate treats hyperkalemia, hypocalcemia, and magnesium toxicity.

The correct dietary teaching is consistency, not avoidance. Green leafy vegetables such as spinach, kale, broccoli, and Brussels sprouts are rich in vitamin K, and wide swings in intake cause the INR to drift. Telling a client to eliminate these foods is outdated and nutritionally harmful; the goal is a steady amount week to week so the warfarin dose can be titrated around it. Citrus juice, dairy products, and protein intake do not meaningfully alter INR, although grapefruit and cranberry juice in large volumes and alcohol binges warrant caution. The client should also report black or tarry stools, bleeding gums, and unusual bruising.

A short-acting beta-2 agonist such as albuterol is the first-line rescue medication in an acute exacerbation because it produces bronchodilation within minutes by relaxing airway smooth muscle. It is typically given as repeated nebulized doses or by metered-dose inhaler with spacer, often combined with ipratropium in the emergency setting. Inhaled corticosteroids and systemic corticosteroids are essential to treat the underlying airway inflammation, but their onset takes hours, so they follow rather than precede the bronchodilator. Salmeterol is a long-acting agent with a slower onset and is contraindicated as monotherapy for rescue. Montelukast is a controller medication for long-term management and has no role in acute rescue.

A silent chest is an ominous finding, not a reassuring one. Wheezing requires turbulent airflow; when obstruction becomes severe enough that almost no air moves, the wheeze disappears. Combined with a rising respiratory rate, accessory muscle use, and inability to speak in full sentences, a silent chest signals impending respiratory failure and requires immediate escalation, including preparation for intubation.

Early in an exacerbation the client hyperventilates in response to hypoxemia and air hunger, blowing off carbon dioxide and producing respiratory alkalosis with a low PaCO2 and elevated pH. This is why a normalizing or rising PaCO2 in a fatiguing asthmatic is a red flag rather than a sign of improvement: it means ventilation is failing, and respiratory acidosis is a late and dangerous development. Metabolic alkalosis is unrelated to this presentation, and while severe prolonged hypoxemia can eventually generate lactic acidosis, that is not the early pattern. Continuous pulse oximetry, serial peak flows, and reassessment after each bronchodilator treatment guide the response.

Lactated Ringer's is the standard resuscitation fluid for major burns. It is isotonic, closely approximates extracellular fluid, and the lactate is metabolized to bicarbonate, which helps buffer the metabolic acidosis of burn shock. Hypotonic 0.45% sodium chloride and 5% dextrose in water shift into the intracellular space and worsen cerebral and tissue edema without supporting intravascular volume. Colloids such as albumin are generally withheld during the first 12 to 24 hours because capillary leak allows protein to escape into the interstitium; some centers add colloid after that window.

The Parkland calculation is 4 mL x body weight in kilograms x percent TBSA burned: 4 x 80 x 40 = 12,800 mL total for the first 24 hours. Half of that total, 6,400 mL, is given over the first 8 hours, and the remaining 6,400 mL over the following 16 hours. The distractor of 12,800 mL is the full 24-hour volume, and 3,200 mL represents only a quarter. A critical detail is that the clock starts at the time of injury, not the time of admission. This client was burned at 0700 and admitted at 0800, so only 7 hours remain in the first phase and the hourly rate must be recalculated accordingly, roughly 914 mL/hr rather than 800 mL/hr.

The formula is only a starting point; titration is guided by response. Adequate resuscitation in an adult is reflected by urine output of 0.5 mL/kg/hr, about 30 to 50 mL/hr, along with a clearing sensorium, heart rate below 120, and improving base deficit. Pediatric clients are titrated to 1 mL/kg/hr. Chasing higher outputs causes fluid creep, abdominal compartment syndrome, and pulmonary edema.

During an active generalized tonic-clonic seizure the nurse cannot stop the seizure, so care focuses on airway and injury prevention. Turning the client to a side-lying position lets saliva and secretions drain from the mouth and keeps the tongue from occluding the airway, while padding or cradling the head prevents blunt trauma. Restraining the extremities does not shorten the seizure and can cause fractures, dislocations, and soft tissue injury. A rapid neurologic examination is meaningless during the convulsion and is deferred to the postictal period.

Forcing an object such as a tongue blade, padded spoon, or gloved finger into the mouth is contraindicated. It can break teeth, lacerate the oral mucosa, push the tongue backward, obstruct the airway, or result in a bite injury to the nurse. The old teaching that a client can swallow the tongue is false. Loosening restrictive clothing, clearing furniture and hard objects from the area, and timing the seizure are all appropriate. Timing matters clinically: a convulsion lasting five minutes or longer, or repeated seizures without return to baseline between them, meets the definition of status epilepticus and requires emergency benzodiazepine administration such as IV lorazepam.

The postictal phase typically involves drowsiness, confusion, headache, muscle soreness, and amnesia for the event, sometimes lasting minutes to hours. The nurse maintains a side-lying position, provides oxygen and suction as needed, reorients calmly, and keeps the environment quiet until the client returns to baseline. Permanent hemiparesis is not expected; transient focal weakness after a seizure, known as Todd paralysis, resolves within hours. Standing seizure precautions include keeping the bed in the lowest position with rails up and padded, oxygen and suction at the bedside, and no oral temperature measurement.

Acute change in body weight is the gold standard for quantifying fluid loss in children because 1 kg of weight equals approximately 1 liter of fluid. This child dropped from 13 kg to 12 kg, a loss of 1 kg or roughly 7.7% of body weight, which places the child in the moderate dehydration range of 6% to 9%. Serum sodium describes the type of dehydration, not the volume lost. Urine specific gravity and skin turgor are supportive assessment findings but are influenced by many other variables and are far less precise.

Oral rehydration solution is the recommended first-line therapy for mild to moderate dehydration, given as approximately 50 to 100 mL/kg over 3 to 4 hours in small frequent amounts such as 5 to 10 mL every few minutes, with additional replacement for ongoing stool losses. Small volumes are better tolerated and vomiting is not a contraindication. Plain water lacks sodium and glucose and can precipitate hyponatremia and seizures in a small child. Fruit juices and sodas have a high osmotic sugar load and inadequate electrolytes, which worsens osmotic diarrhea. Intravenous fluids are reserved for failed oral therapy, severe dehydration, or altered mental status.

If the child progresses to hypovolemic shock, resuscitation begins with a 20 mL/kg bolus of an isotonic crystalloid such as 0.9% sodium chloride or lactated Ringer's, which equals 240 mL for this 12 kg child, infused rapidly over 5 to 20 minutes and repeated based on reassessment. A 10 mL/kg bolus is too small for shock in this setting, 50 mL/kg is not a single bolus dose, and hypotonic 0.45% sodium chloride is never used for volume resuscitation because it does not stay in the intravascular space.

A hypertensive emergency is defined as a systolic pressure above 180 mm Hg or diastolic above 120 mm Hg accompanied by evidence of acute target organ damage. This client has papilledema and flame hemorrhages, which represent acute hypertensive retinopathy (target organ damage), and the headache, blurred vision, and nausea raise concern for hypertensive encephalopathy, so this is an emergency rather than an urgency. Hypertensive urgency describes the same severe pressures without acute organ injury and is managed with oral agents and close outpatient follow-up rather than intravenous therapy. Stage 2 hypertension refers to chronic readings of 140/90 mm Hg or higher and is a diagnostic category, not an acute crisis. White coat hypertension is elevation confined to the clinical setting and would not produce papilledema.

Hypertensive emergencies require titratable intravenous agents in a monitored setting. Nicardipine, clevidipine, labetalol, esmolol, and nitroglycerin are common choices, selected according to the organ involved; nitroglycerin is favored in acute coronary syndrome and esmolol or labetalol in aortic dissection. Nicardipine is a reasonable first choice for hypertensive encephalopathy. Immediate-release nifedipine given sublingually is dangerous and obsolete because it causes abrupt, unpredictable pressure drops leading to stroke and myocardial infarction. Hydrochlorothiazide is an oral maintenance drug with far too slow an onset. Enoxaparin is an anticoagulant and has no role in blood pressure control.

Blood pressure must be lowered gradually. The standard target is a reduction of no more than 25% of the mean arterial pressure within the first hour, then toward 160/100 to 110 mm Hg over the next 2 to 6 hours, and to normal over 24 to 48 hours. Chronic hypertension shifts cerebral autoregulation rightward, so a rapid drop to a normal value causes cerebral, coronary, and renal hypoperfusion and infarction. Exceptions exist for aortic dissection, which requires a systolic pressure below 120 mm Hg within 20 minutes.

Semi-Fowler position, with the head of the bed elevated 30 to 45 degrees, uses gravity to keep any peritoneal fluid or purulent drainage in the lower abdomen and pelvis, away from the diaphragm. This lowers the risk of a subdiaphragmatic abscess, which is a real concern after a perforated appendix, and it also improves diaphragmatic excursion and comfort. Trendelenburg does the opposite by directing contaminated fluid upward toward the diaphragm. A flat supine position provides no drainage advantage and worsens splinting, and left lateral recumbent positioning has no specific benefit here.

Incentive spirometry with incisional splinting is the core intervention for preventing atelectasis and postoperative pneumonia. Sustained maximal inspiration reopens collapsed alveoli, and holding a pillow against the incision reduces pain enough that the client will actually take deep breaths, cough, and ambulate. Rebreathing into a paper bag is not an accepted intervention and risks hypoxemia. Pursed-lip breathing helps clients with obstructive disease control exhalation but does not recruit alveoli. Immobility is the direct cause of atelectasis and venous thromboembolism, not a protective measure.

A rigid, board-like abdomen with a fever of 102.4 F signals peritonitis, which after a perforated appendix may indicate a spreading intra-abdominal infection or abscess and requires immediate surgical evaluation. The other findings are expected. Bowel sounds are commonly absent for a period after abdominal surgery because of transient ileus from anesthesia and manipulation. A small amount of serosanguineous drainage on a port-site dressing is normal early healing. Shoulder discomfort is a classic and self-limited consequence of residual carbon dioxide insufflation irritating the diaphragm after laparoscopy, and it resolves with ambulation and analgesia. The nurse should also monitor for a low-grade temperature, which is common in the first 48 hours.

Tidaling, the gentle rise and fall of the water-seal fluid with respiration, reflects normal changes in intrapleural pressure and confirms the system is patent. The fluid rises with inspiration and falls with expiration in a spontaneously breathing client, and the pattern reverses with positive-pressure ventilation. Tidaling that suddenly stops suggests either lung reexpansion, which is the desired outcome, or an obstruction such as a kink or clot, so it must be correlated with the client's respiratory status and chest imaging.

Intermittent bubbling in the water-seal chamber during forceful expiration or coughing is normal in the early postoperative period as pleural air evacuates. Continuous bubbling indicates an air leak, and the nurse's first action is to locate it by assessing the insertion site dressing and systematically checking the tubing connections, moving from the client toward the drainage unit. Clamping a chest tube is generally avoided because trapped air can convert a simple pneumothorax into a life-threatening tension pneumothorax; it is reserved for specific situations per provider order or facility policy, such as brief clamping to locate a leak or change the drainage unit, or a trial clamp before tube removal. Routine milking and stripping generates dangerously high negative pressures and tissue trauma and is not recommended. Increasing suction does not fix a leak and may worsen it. Note that gentle continuous bubbling in the suction control chamber of a wet system is expected and simply reflects the suction level.

If the tube is dislodged from the chest, the nurse immediately covers the wound with a sterile occlusive dressing secured on three sides. This creates a flutter valve that allows air to escape during exhalation while preventing air from being drawn into the pleural space during inhalation. Taping all four sides traps air and can cause a tension pneumothorax. Nurses do not reinsert chest tubes, and leaving the site open allows continued atmospheric entry. The nurse then assesses respiratory status and notifies the provider.