ARCHER NEXT GEN NCLEX QUESTIONS

ARCHER NEXT GEN NCLEX QUESTIONS

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX-RN Practice Questions For 2...Teacher 33 terms TutorDkPreview NCLEX RN Test 1 2024-2025 Teacher 312 terms TutorDkPreview 75 Free 75 terms car The nurse is reviewing laboratory data for a client suspected of having a myocardial infarction. The nurse anticipates that the CK-MB isoenzyme will peak within how many hours?

• 3-6 hours
• 1-2 hours
• 48-72 hours
• 18 hours
• 3-6 hours

-CK-MB, or creatinine kinase myocardial muscle, levels measure muscle cell death and are at their highest elevation 18 hours after cardiac muscle damage. CK-MB levels begin elevating about 3-6 hours after a cellular injury or MI. Between 48-72 hours, the levels will start to decrease after reaching the peak at 18 hours following cardiac muscle damage.The nurse is triaging a child with suspected impetigo.Which action should the nurse take? SATA

• initiate droplet precautions
• set up a decontamination room
• use a disposable blood pressure cuff
• initiate contact precautions
• apply sterile gloves while examining the client
• initiate droplet precautions
• use a disposable blood pressure cuff

Impetigo is a contagious infection of the skin commonly seen in young children.This condition is highly infectious, and the nurse should utilize disposable equipment. Contact precautions require the nurse to wear a gown and gloves when engaging in client care.

The nurse is reviewing the medical records of clients who have sustained several falls. While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?

SATA

• fluoxetine
• temazepam
• bupropion
• ferrous sulfate
• hydrocodone-acetaminophen
• hydroxyzine
• docusate
• temazepam

-indicated in treatment of insomnia and is a benzodiazepine -alternative -> melatonin

• hydrocodone-acetaminophen

-indicated in pain treatment -is an opioid and may lead to falls due to its CNS-depressing effects

• hydroxyzine

-is an anticholinergic indicated for allergic rhinitis and anxiety -clouds sensorium of older adults, which may cause falls -medications directly implicated in the causation of falls include benzodiazepines, opioids, anticholinergics, and antihypertensives The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?

• "Egg allergy is a contraindication to giving this vaccine"
• "This is a 3 series vaccine that should be started at

birth"

• "It is safe for breastfeeding women to receive the MMR

vaccine"

• "This vaccine is safe if the client is pregnant"
• "It is safe for breastfeeding women to receive the MMR vaccine"

The MMR vaccine is safe to administer to a client who is breastfeeding. No evidence exists of this vaccine being weakened by breastfeeding.The nurse is caring for a client receiving a terbutaline infusion to prevent preterm labor. Which clinical finding indicates that the nurse should continue the infusion?

• blood pressure 91/58
• heart rate 132 BPM
• serum potassium 3.3 mEq/L (3.5-5)
• blood glucose 104 mg/dL (70-110)
• blood glucose 104 mg/dL (70-110)

-Terbutaline may increase client's blood glucose level. Nurse should monitor client's blood sugar levels while on this medication. This glucose level is normal and indicates to the nurse that the infusion may continue.The nurse is assessing a client with suspected acute glomerulonephritis (AGN). Which of the following findings would support a diagnosis of acute glomerulonephritis? SATA

• metabolic acidosis
• increased serum creatinine
• hematuria
• costovertebral tenderness
• increased serum ammonia level
• hypovolemia
• metabolic alkalosis
• increased serum creatinine

-renal insufficiency is hallmark of AGN. Client will have increased BUN and creatinine

• hematuria

-AGN causes hematuria because of significant inflammation occurring in glomerulus

• costovertebral tenderness
• increased serum ammonia level
• hypovolemia

The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision?

• adjust the physician's order based on the client's pain

level

• ensure naloxone is always available
• check the client's blood pressure before administering

morphine sulfate

• provide a high-fiber diet
• adjust the physician's order based on the client's pain level

-Pain med orders may be titrated based on the client's pain level. However, the nurse cannot adjust the physician's order based on the client's pain level. If the nurse wants to adjust the dosage, the nurse will need the MD to adjust the prescription.

• ensure naloxone is always available

-Naloxone, an opioid antagonist, should always be available as an antidote to opioids and to treat opioid overdose, including events occurring with morphine sulfate.

• check the client's blood pressure before administering morphine sulfate

-morphine sulfate has a vasodilation effect, which may lower blood pressure. Prior to administration, the nurse should assess the client's blood pressure and respiratory rate.

• provide a high-fiber diet

-Morphine sulfate diminishes propulsive peristaltic waves in the GI tract, resulting in constipation. A high-fiber diet should be given to prevent this complication.While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? SATA

• intrauterine growth restriction
• hemolytic disease of newborn
• hydrocephaly
• large for gestational age infant
• still birth
• intrauterine growth restriction
• hemolytic disease of newborn

-hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh- and is pregnant with an Rh+ baby

• hydrocephaly
• large for gestational age infant
• still birth

-a,c,e -> women infected with rubella are at an increased risk of having a miscarriage or stillbirth. Their infants are more likely to suffer from IUGR and hydrocephaly The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which

PPE? SATA

• goggles
• gown
• gloves
• shoe covers
• N95 respirator
• surgical face mask
• goggles
• gown
• gloves
• shoe covers
• N95 respirator
• surgical face mask

Rationale A disseminated herpes zoster is a case where the rash spreads beyond the primary area. When it is disseminated, it can be transmitted through airborne means and by direct contact with lesions. The isolation required is contact + airborne. This means that the nurse should wear an N95 respirator, high-efficiency particulate air filter respirator, gown, and gloves.

The nurse is reviewing leadership and management concepts with a student nurse. The student demonstrates understanding if they made which of the following statements? SATA

• "Battery is an intentional touching of another's body

without the other's consent"

• "Assault is when the nurse makes a verbal or physical

threat"

• "Unintentional torts include negligence and

malpractice"

• "Defamation is presenting false credentials for

employment"

• "Occurrence reports reduce the liability for a liability

for a negligent tort"

• "Battery is an intentional touching of another's body without the other's consent"
• "Assault is when the nurse makes a verbal or physical threat"
• "Unintentional torts include negligence and malpractice"
• "Defamation is presenting false credentials for employment"
• "Occurrence reports reduce the liability for a liability for a negligent tort"

The nurse is caring for a client with a major thermal burn.Which initial lab abnormalities does the nurse anticipate in response to the burn?

• hemodilution
• hyperkalemia
• metabolic acidosis
• hyperglycemia
• hemoconcentration
• hemodilution
• hyperkalemia
• metabolic acidosis
• hyperglycemia
• hemoconcentration

Rationale Following a major burn, significant fluid and electrolyte changes occur from cell damage, which causes potassium to leak out into the extracellular space. Thus, life-threatening hyperkalemia can occur. Metabolic acidosis is likely because of the impairment the burn causes to the kidney's ability to recycle bicarbonate. The discharge of catecholamines causes glucose release form the liver, raising the blood glucose. Finally, the loss of fluid causes hemoconcentration, illustrated by elevated hematocrit.The nurse is observing infection control practices on the nursing unit. Which of the following findings requires follow-up?

• doors kept closed for clients with contact precautions
• gloves being worn by staff to pass meal trays
• disposable dishes being used for clients on isolation

precautions

• bedside fan being removed from a room with negative

pressure

• alcohol-based hand sanitizers for a client with c. diff
• doors kept closed for clients with contact precautions

-contact precautions do not require client's door to be kept closed, only for airborne precautions

• gloves being worn by staff to pass meal trays

-gloves should not be worn while passing or collecting meal trays, and are only worn when contact with blood or bodily fluids are likely

• disposable dishes being used for clients on isolation precautions

-disposable dishes are not used for clients on any isolation precautions

• bedside fan being removed from a room with negative pressure
• alcohol-based hand sanitizers for a client with c. diff