NCLEX

an O2 level of 88% on room air is when oxygen is prescribed for a person and this is to keep the oxygen level greater than 92%
forced vital capacity is not timed
beta blockers are contraindicated for pt’s with COPD and asthma. lol- propanolol, metoprolol
check peripheral pulses after a catheter cath insertion
when a client has liver surgery it is common for the pt. to have pain on the shoulder.
if pt. feels tightness after surgery this indicates internal bleeding
liver surgery position pt on right side with pillow under the lower rib to prevent hemorrhaging
correct placement for pulse ox for raynaud’s disease is lobe of the ear and bridge of the nose
#1 cause of SIADH is lung cancer
septic shock leads to DIC
coarse wheezes after a trach placement is to be expected. suction pressure should be 80-120 mmhg.
IV lasix cause hypotension check bp
po lasix risk for changes in potassium
LPNs can suction as long as the pt is stable
NAPs can adm. enteral feedings through tube
feeding a pt diagnosed with myasthenia gravis can only be done by a nurse
singed nose hair, burns in chest = smoke inhalation
percut dressings is the only dressing used for trach patients.
never use powder for trach pt’s
never instill NS into tracheostomy instead use humidified air to moisten secretions
hypoxic pt’s are seen first confused, diaphoretic, and dyspneic
graduate nurse get only one shot for any skill if they make a mistake the RN will take over.
an unidentified substance don’t pick the answer choice that says “go figure out what it is “
decontamination that already occurred = unknown substance
do not put pts that are brand new post op with pts with cellulitis, prednisone, or chest pt.
meningitis, measles, chicken pox, c-diff, MRSA, influenza all get private rooms
upper respiratory do not get private rooms
standard precaution get semi private rooms
pts who are highly unstable, high risk for falls, confused go near the nurses station
padded tongue blades, intubation tray, CPR are not needed for seizure precaution
suction equipment, o2 equipment are need for seizure precautions
padded side rails is wrong for seizure precautions
mattress on the floor is a better option for seizure precaution
pt’s with internal radiation implant the maximum time you can spend with pt is 30 minutes whether its the nurse has an 8 or 12 hour shift.
for stairs = up with the strong leg
down the stairs = down with the weak leg
degenerative disease use large joints over small joints
thyroid storm switch from 0.9% NS to D5W
never give aspirin to pt with thyroid storm causes more diuretic hormones to go into blood stream.
confusion is a sign of toxicity
the elderly are at risk for tagamet (anti ulcer) toxicity
RNs can educate, assess first sets of vs / after procedure, use nursing judgment to decide whether a pt is stable or not.
LPNs/ LVN can take care of stable pt’s with expected outcomes
float nurse can never refuse to be floated. float nurse should not be forced to teach. uses LPN/LVN guidelines
LPNs cannot discharge a pt. LPNs can do a steril procedures and can insert catheters.
ethical issues go to line manager
line manager = charge nurse, supervisor
never document these 3 statements:
“v/s stable”
“mistakenly or accidentally”
“incident report completed” reports then become part of the pt’s chart. instead write “physician noted”
don not write “I” when charting. instead write ” this”
compartment syndrome= severe pain to the limb, weak palpable pulses
low grade temp is expected after surgery
never aspirate prior to injecting heparin only do this for IMs.
risk for falls should be assessed when pt is first admitted to the floor. needs to be done immediately.
ovarian, endometrial, and colon cancer are at risk for breast cancer
if mother used heroin or any other drug you will see withdrawal in infant after 12 -24 hrs
after a baby is born it takes 2 wks for the baby to develop a milk allergy.
smoking increases your risk for arthritis
for someone to be able to use an IUD (intrauterine device ) you need to be in a monogamous relationship.
tetanus, diptheria, and pertussis is given every 10 yrs
yes and no q’s only for suicide
antidepressant drugs don’t take into effect until 5-6 wks . 3-5 wks at risk for suicide
increase temp is a sign of cocaine use. cocaine use causes vasoconstriction. overdose can cause MI
regression behavior
ex. an adult who throws a temper tantrum. or behavior that is appropriate at a younger age.
projection behavior
ex the client blames someone or something other than the source.
reaction formation
the client acts in opposition to his feelings
intellectualization behavior
the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.
reyes syndrome is dx by
liver biopsy
drug to treat tourette syndrome
haloperidol
client with
skin: dark bronze
urine: dark color
temp: 99.5F
hematocrit: 49
hemoglobin: 9 g/ dl (low)
RBC: 2.75 million (low)
initiate an intake and output record. client is exhibiting clinical manifestations of anemia with jaundice and is demonstrating a fluid imbalance
a s/s of dumping syndrome after a subtotal gastrectomy is
diaphoresis and diarrhea
diseases that can be transmitted by a blood donor includes
– epstein barr virus
– HIV
– cytomegalovirus
the priority of an escharotomy is
tissue perfusion
pt is treated for SIADH what are the expected out comes ?
-increase in urine output
-decreased in osmolarity
-decrease in body weight and edema
pt with meningitis is what infection control ?
droplet precaution
nurse should wear gloves, mask, and eye protection during suctioning. apply a mask to face for transport
The nurse is administering an ACTH stimulation test to a patient suspected of having Addison’s disease. Which of the following is true regarding the ACTH stimulation test?
Blood is drawn at baseline, 30 minutes and 60 minutes after ACTH administration
•First, cortisol and ACTH levels are drawn at baseline. Next, the nurse administers synthetic ACTH, I.V. Finally, cortisol and ACTH levels should be drawn at 30 minutes and 60 minutes after ACTH administration.
•ACTH stimulation test is used to assess the adrenal glands response to stress. This is used to help diagnose or exclude Addison’s diease and adrenal insufficiency.
The nurse understands that if a client continues to be dependent on heroin throughout her pregnancy, her baby will be at high risk for:
Heroin dependence.
A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client?
-reduces myocardial oxygen consumption
-reduces BP and HR
-reduces anxiety and fear
a nurse is instructing a client on the appropriate placement of the client’s nitroglycerin patch (minitran). Which of the following responses indicates understanding of the teaching .
Client should remove the patch each evening for a medication free time of 12 to 14 hr before applying a new patch.
a child with a known seizure disorder is hospitalized for an appendectomy. while assisting the child back from the restroom, the child begins tonic-clonic movements. The nurse should take which action in order of priority from 1st to last.
1. note the time
2. ease the child to the floor
3. clear the area of potentially harmful objects and pad the head
4. roll the child to the side
a client is in isolation after receiving an internal radioactive implant to tx cancer. two hours later, the nurse discovers the implant in the bed linens. what should the nurse do first
nures should immediately leave the room and notify the radiation therapy department. the nurse shouldn’t attempt to handle the implant or remain in the room with the implant.
a client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
the clients viral loads is extremely low so he is relatively free of circulating virus. this indicates that the client has a low risk for opportunistic illnesses.
a nurse is preparing to care for a client after a lumbar puncture. The nurse plans to place the client in which best position immediately after the procedure?
prone with a small pillow under the abdomen
the nurse supervises a NA on a neuroscience acute unit care. which of the following tasks should the nurse assign to the NA?
administer ENTERAL FEEDING through a gastrostomy tube to a client dx with a ruptured cerebral aneurysm.
after a child had a tonsillectomy procedure. the nurse should place the child in a
child is place in PRONE or SIDE LYING position after tonsillectomy to facilitate drainage
A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean that the client has:
1. Active TB
2. Had contact with Mycobacterium tuberculosis
the contact with mycobacterium tuberculosis
A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists.
Which of the following nursing interventions should be included in the client’s care plan during dialysis therapy?
2. Monitor the client’s blood pressure
4. Keep the client NPO.
monitor the client’s BP
Because hypotension is a complication of peritoneal dialysis, the nurse records intake and output, monitors VS, and observes the client’s behavior.
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because:

It can develop into ventricular fibrillation at any time.

Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Client’s frequently experience a feeling of impending death. Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.

A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?
Start prophylactic AZT treatment
A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
B: Diabetic nephropathy
C: Autonomic neuropathy
D: Somatic neuropathy
automonic neuropathy
can cause inability to urinate
The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for:
Headache, deteriorating level of consciousness, and twitching.
Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
atrial fibrillation is receiving coumadin what is the therapeutic INR
2-3
Atrial tachycardia EKG strip characteristic
regular atrial and ventricular rhythms, P wave hidden in the T wave, rate ranges from 140 to 210 bpm
atrial flutter EKG strip characteristic
atrial rate greater than the ventricular rate, SAW TOOTH P waves
atrial fibrillation EKG strip characteristic
irregular rhythm, indiscernible atrial rate, absent P waves
sinus tachycardia EKG strip characteristic
regular and equal atrial ventricular rhythms and a rate of 100 to 160 bpm
the nurse is caring for a client with ACCELERATED silicosis. the nurse would expect
rapidly progressing symptoms and x-ray changes
ACUTE silicosis reveals
rapid onset of dyspnea, cough, weight loss. x-ray reveals a GROUND-GLASS APPEARANCE
Which is the correct term for the ability of the kidneys to clear solutes from the plasma?
Renal clearance
Which type of incontinency refers to the involuntary loss of urine due to medications?
Iatrogenic
A client with chest pain is admitted to the ED. He states that his chest pain was not relieved after taking 3 nitroglycerine tablets at home. Which of the following is the best initial nursing action?
administer the prescribed analgesic
relief of chest pain is a priority in myocardial infarction. Pain increases cardiac workload and may lead to shock. Morphine sulfate is the drug of choice.
which of the following actions should the nurse take to decrease the potential for raising client ICP
-suction the endotracheal tube
-hyperventilate the client
-administer stool softener
DO NOT elevate the head with 2 pillows and DO NOT keep the client well hydrated
pt. admitted to the Telemetry Unit for evaluation of complaints of chest pain. 8 hrs after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to:
cause asystole so the normal pacemaker can recapture
A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be moSt important for a nurse to monitor which of the following laboratory values in this patient?
BUN and creatinine
nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance
A patient with an obstruction of the renal artery causing renal ischemia exhibits HTN. One factor that may contribute to HTN:
increase renin release
The nurse in the same-day surgery department cares for a 77-year-old woman after a sigmoidoscopy. Which of the following symptoms, if exhibited by the woman an hour after the procedure, would MOST concern the nurse?
The client complains of lightheadedness and dizziness. This could signify hypovolemic shock due to bowel perforation
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for PKU?
I will schedule a home visit for PKU screening when the baby is 3 days old. needs time to ingest protein sources of phenylalanine.
pulmonary capillary wedge pressures
measures pressure form fluid within the left ventricle
it guides the physician in determining fluid management for the client.
pulmonary artery pressure
are used to assess the heart’s ability to receive and pump blood.
pulmonary artery catheter
provides info about left ventricular functioning
the most important nursing action when measuring a pulmonary capillary wedge pressure PCWP
deflate the balloon as soon as the PWCP is measured
A 22 month old infant is to have MODERATE sedation for an outpatient procedure. The nurse knows that:
(The infant should respond to gentle tactile or verbal stimulation )
infants under GENERAL anasthesia have decreased or absent reflexes.
The nurse cares for an 8-lb, 8-oz newborn. The infant’s hX indicates the mother was given magnesium sulfate IV 4 g in 250 mL D5W several hours before delivery. The nurse is MOST concerned if which of the following was observed?
1. Temperature 97.6°F (36.5°C).
2. Apical pulse 140 bpm.
3. Respirations 18/min.
4. BP 80/50
RESPIRATIONS 18/MIN
magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
a client with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. The nurse should monitor the client for which adverse effects of external radiation ? SATA
XEROSTOMIA -dry mouth
STOMATITIS- irritation of the mucous membrane
DYSGEUSIA- diminished taste
BP in the systemic circulation is HIGHEST in the
AORTA
which of the following food choices is high in fiber? SATA
1. canned peaches 2. white rice
3.black beans 4. whole grain bread
5. tomato juice
BLACK BEANS
WHOLE GRAIN BREAD
a nurse is caring for a client who has bladder spasms 1 day post op following a TURP. the client’s urinary drainage bag contains the same amount of urine it did 3 hrs ago. Which of the following actions is the appropriate intervention?
IRRIGATE THE CATHETER WITH A SYRINGE AND 50 ML OF STERILE IRRIGATING SOLUTION
blood clots that commonly drain from the bladder after TURP can block the drainage system. Irrigating the catheter will flush out the clots and allow urine and irrigating fluid to drain.
a nurse is providing teaching to the mother of a child dx with kawasaki disease.which of the following statements by the mother indicates that the teaching was effective? SATA
“MY CHILD WILL BE IRRITABLE FOR THE NEXT FEW WEEKS” children with kawasaki disease will be irritable for up to 2 months
“I WILL KEEP A RECORD OF MY CHILD’S TEMPERATURE UNTIL SHE HAS NO FEVER”
A client had 20 mg of lasix (Furosemide) PO at 10am. Which would be essential for the nurse to include at the change of shift report?
A. The client lost 2 pounds
B. The client’s K level is 4meq/L
C. The client’s urine output was 1500 cc in five hours
D. The client is to receive another dose of Lasix at 10pm
The client’s urine output was 1500 cc in five hours
a nurse is monitoring the chest tube drainage system in a client with a chest tube. the nurse note intermittent bubbling in the water seal chamber. Which of the following is the appropriate action?
DOCUMENT THE FINDINGS
bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one its purposes, removing air from the bubble space. continuous bubbling during inspiration and expiration indicates that an air leak exists. if this occurs, it must be corrected.
The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician?
1. Furosemide (Lasix) 20 mg IV every 12 hours.
2. 2 g/day sodium diet
3. Normal saline at 125 ml/hour IV.
4. Oxygen at 2 L per nasal cannula
NORMAL SALINE AT 125 ML/HR
because the patient may have excess fluid volume, may be on fluid volume restriction; weigh daily and measure I and O
appropriate order; loop diuretic that promotes the excretion of excess water; decreases blood volume and pressure in the left ventricle
A client has a subclavian triple lumen catheter used for administration of total parenteral nutrition (TPN). The physician orders all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should take which of the following actions?
1. Clamp off the lumen and label it as “clotted off.”
3. Aspirate blood from the lumen to restore patency.
4. Secure the lumen with a Luer-Lock cap and notify the physician.
4. Secure the lumen with a Luer-Lock cap and notify the physician.
streptokinase may be used to dissolve clot; if unsuccessful, lumen is labeled as clotted off
(1) should be reported to the physician to see if patency can be re-established before it is labeled as clotted off
(2) force should never be used to irrigate the catheter
(3) blood should not be aspirated from the catheter
The Doc had prescribed Cortone(cortisone) for a client with systemic Lupus erythematosis. Which instruction should be given to the patient?
A. Report weight and appetite changes.
B. Wear sunglasses to prevent cataracts.
C. Schedule to take the flu vaccine
D. Take medication 30 mins before eating
schedule to take the flu vaccine
Nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the clients diagnosis?
sweat chloride concentration greater than 60.
9 yr old is admitted w suspected rheumatic fever. Which finding is suggestive of Sydenham’s chorea?
irregular movement of extremities n facial grimace.
Doc has ordered increased oral hydration for a client with renal calculi. Unless contraindicated, the recommended oral intake for helping remove renal calculi is
200 ml per hour
A client admitted w a diagnosis of polycythemia Vera. The nurse should closely monitor the client for
increase BP
Polycythemia vera is a bone marrow disease that leads to an abnormal increase in the number of blood cells. The red blood cells are mostly affected.
Who is at greatest risk for latex allergy?
A child with myelomeningocele
B child with coxa plana
C child with rheumatic fever
D child with epispadias
child with myelomeningocele
This is due to all the surgeries and dressing changes that will occur.
The nurse cares for clients in the postanesthesia care unit (PACU). Which of the following clients require IMMEDIATE attention by the nurse?
1. A client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing.
2. A client who is responsive with a moderate amount of clear fluid draining from the NG tube.
3. A client with a chest tube and dark red drainage in the collection chamber.
4. A client who is unresponsive to verbal stimuli with the oral airway out of place.
4. A client who is unresponsive to verbal stimuli with the oral airway out of place.
The nurse knows which of the following observations is indicative of chronic cocaine use?
Nasal septum disruption.
The nurse cares for clients in the pediatric clinic. A mother reports that her infant’s smile is “crooked”. The nurse should assess which of the following cranial nerves?
1. III.
2. V.
3. VII.
4. XI.
3. VII facial; provides motor activity to the facial muscles
The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?
1.Asystole
2.Atrial fibrillation
3.Ventricular fibrillation
4.Ventricular tachycardia
3.Ventricular fibrillation
Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles
A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?
1.Sensation of palpitations
2.Causative factors, such as caffeine
3.Precipitating factors, such as infection
4.Blood pressure and oxygen saturation
4.Blood pressure and oxygen saturation
Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

A plan of care is created for a term small-for-gestational-age (SGA) neonate who was admitted to the neonatal intensive care unit (NICU). The goal was for the newborn to reach 5 pounds by a specified date. On the specified date …

A 62-year-old client is admitted for hypertension, and serum electrolyte studies have yielded abnormal results. The scheduled workup includes a scan for an aldosteronoma. The nurse concludes that this scan is ordered to rule out disease of the: 1. Kidney …

1. When formulating a definition of “health,” the nurse should consider that health, within its current definition, is: 1. The absence of disease 2. A function of the physiological state 3. The ability to pursue activities of daily living 4. …

A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion …

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