1 | UWorld NCLEX-PN

• | UWorld NCLEX-PN
• studiers in 3 days 5.0 (1 review)

Students also studied Terms in this set (124) Science MedicineNursing Save Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview random missed questions nclex pra...27 terms elizabeth_kolkebeck Preview NCLEX-PN 3000 Questions 83 terms cutiemexiPreview

• | UWo

82 terms rea The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time?

• Cleanse the incision site with saline and apply a new,

sterile dressing

• Mark the edges of the drainage on the dressing and

continue to monitor

• Notify the health care provider of the color and

amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique

CORRECT ANSWER: 3

A craniotomy involves incision into the cranium and is indicated for elevated intracranial pressure or removal of tumors, blood, or abscesses. Postoperative clients are at risk for developing a cerebrospinal fluid (CSF) leak from an intraoperative dural injury, which increases the risk for meningitis.Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into the drain) or from the nose or ear suggests a possible CF leak requiring immediate notification of the health care provider (HCP) (Option 3 is correct).Interventions focus on decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain placement, and surgical intervention.(Option 1 is wrong) The incision should not be re-dressed until the HCP can evaluate the wound and drainage.(Option 2 is wrong) The nurse should mark the drainage edges at least once per shift for comparison. However, a saturated dressing may indicate a CSF leak.(Option 4 is wrong) Repositioning may be indicated but is not the most appropriate action at this time. Specific client positioning postoperative craniotomy is prescribed by the HCP. The head of the bed is usually elevated approximately 30 degrees to facilitate venous drainage and prevent increased intracranial pressure. If flat positioning is prescribed, the nurse should log-roll the client to alternate between the back and the nonoperative side.

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the nurse? Select all that apply.

• The UAP adds milk to mashed potatoes to make them

thinner.

• The UAP encourages the client to occasionally turn the

head to the left.

• The UAP helps the client sit in an upright position.
• The UAP places food on the strong side of the client's

mouth.

• The UAP puts a straw in a fruit smoothie to prevent

spilling.

CORRECT ANSWER: 1, 5

Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration.Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.

• Amphetamine use
• Cigarette smoking
• Cold exposure
• Deep sleep
• Sexual intercourse

CORRECT ANSWER: 1, 2, 3, 5

Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina,

including the following:

• Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) • Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload

• Temperature extremes: Usually cold exposure and hypothermia

(vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling)

• Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon

monoxide; nicotine causes vasoconstriction and catecholamine release

• Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause

vasoconstriction

• Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm):

Decreases blood flow to myocardium (Option 4 is wrong) Deep sleep doesn't increase oxygen demand.

A client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the image. The nurse recognizes it as which rhythm? Go to the image link below for more information.Image: https://imgur.com/qPQ6jW3

• Complete heart block
• 1st-degree heart block
• Sinus bradycardia
• Sinus rhythm

CORRECT ANSWER: 3

Go to this image for more help about this question: https://imgur.com/j4xFw2a Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60>0.20 second.(Option 4 is wrong) Sinus rhythm has a rate of 60-100/min.The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

• Check for a carotid pulse for at least 10 seconds.
• Provide rescue breaths at a rate of 10-12/min.
• Resume chest compressions at a rate of 100/min.
• Use the jaw-thrust maneuver to assess the airway.

CORRECT ANSWER: 3

The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions immediately (Option 3 is correct).(Option 1 is wrong.) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall.(Option 2 is wrong.) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths.(Option 4 is wrong.) The jaw-thrust maneuver is used instead of the head-tilt/chin- lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is not indicated at this time.

The client is scheduled to have a cardiac catheterization.Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply.

• Elevated serum C-reactive protein level
• History of previous allergic reaction to IV contrast
• Prolonged PR interval on ECG
• Received metformin today for type 2 diabetes mellitus
• Serum creatinine of 2.5 mg/dl (221 umol/L).

CORRECT ANSWER: 2, 4, 5

Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries.

Potential complications of IV iodinated contrast include:

• Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2 is correct).• Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4 is correct).• Contrast-induced nephropathy: lodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 mol/L1).Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary (Option 5 is correct.).(Option 1 is wrong.) C-reactive protein, produced during acute inflammation, may indicate elevated risk for coronary artery disease. However, it is not an indicator of an acute cardiac event and is not a safety concern for cardiac catherization.(Option 3 is wrong.) First-degree atrioventricular block may precede more serious conditions However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blocker, digoxin). This would not prevent the procedure from proceeding.