NCLEX readiness

NCLEX readiness Leave the first rating Students also studied Terms in this set (55) Science MedicineNursing Save Elevate Module 1 25 terms brookeekitchens Preview Elevate Module 1 25 terms mkgrondin07Preview HURST Mod 1 25 terms Jessica_Burress9 Preview MedSu 137 term jshi In what order should the nurse assess assigned clients following shift report?

• Client admitted with chemotherapy-induced

neutropenia with a temperature of 100.8 F (38.2 C).

• Client diagnosed with aplastic anemia needing

education regarding ways to decrease infection risk.

• Client diagnosed with cancer who is crying and states,

"I am not ready to die".

• Client with non-Hodgkin's lymphoma who is refusing

prescribed chemotherapy regimen.

• Client one day post splenectomy.

Order: 1, 5, 3, 4, 2

The first client the nurse needs to assess is the one admitted with chemotherapy- induced neutropenia with a temperature of 100.8 F (38.2 C). Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection. This client will likely need blood cultures and antibiotics quickly.The second client that should be assessed by the nurse is the client who is one day post splenectomy. There is no indication that this client is in any immediate danger, but as a surgical client one day postop, this client should be assessed prior to moving on to the other three clients. The nurse needs to assess for any possible complications associated with surgery.The third client the nurse needs to see is the client diagnosed with cancer who is crying and states, "I am not ready to die". This client is facing death and is exhibiting grief. The role of the nurse is to respond appropriately to the client's needs by listening carefully and addressing the social, emotional and spiritual aspects of the client's symptoms. This client should be seen after clients who have a physical problem that could be life threatening.The fourth client the nurse should assess is the client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen. This client does not need immediate care. The nurse needs to talk to the client about why the client is refusing chemotherapy and if any education or referrals are needed.Clients who are stable and awaiting discharge teaching can be seen last.

Which comment by the mother indicates understanding of the diet needed to maintain health and adequate nutrition in the toddler?

• "It is important to give my child low fat milk after one

year of age".

• "If the child won't eat new foods after three tries, he is

not going to eat it".

• "I think that the sooner one starts to give vitamins to

children, the better".

• "I try to provide whole grains, fruits, vegetables, and

meat daily".

4.The nurse is caring for a client due for a dose of

fluphenazine 10 mg. The drug is available as an elixir: 5

mg / 5 mL. How many mL will the nurse give to the client?______mL.Round answer to the nearest whole number.10 The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply

• Some clients may have dental issues, making chewing

difficult.

• There may be a decreased appetite in clients.
• Caloric and nutritional needs may vary somewhat

depending on activity levels.

• Access to fresh foods is adequate.
• The desire and interest in cooking is increased.

1., 2. & 3. Correct: Many elderly people have dental issues that affect chewing and intake of nutritionally dense foods. Appetite may decrease due to changes in taste, medications, depression or isolation. Many elderly people are active; therefore, it is important to assess each one individually in regard to activity levels.

4. Incorrect: Many elderly clients may not have access to fresh foods due to

infrequent grocery shopping, limited budgets, and a desire to not waste good food.

• Incorrect: Many elderly do not have a desire to cook for one or two. Pain and

physical impairment may also decrease desire or interest in cooking.The nurse inadvertently administered the wrong medication to a client. Place the tasks to be completed in order of priority.

• Alert the Unit Manager.
• Obtain the client's vitals.
• Complete an incident report.
• Report what happened to the health care provider.

2, 4, 1, 3

In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority.UAP reports a heart rate of 40/min in a client.The water seal chamber is empty in a client's closed chest drainage unit.Client's tracheostomy needs to be suctioned.Client who is on bedrest due to a deep vein thrombus attempting to get out of bed.Client reporting urinary frequency and dysuria.Client's tracheostomy needs to be suctioned.The water seal chamber is empty in a client's closed chest drainage unit.UAP reports a heart rate of 40/min in a client.Client who is on bedrest due to a deep vein thrombus attempting to get out of bed.Client reporting urinary frequency and dysuria.

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5ºF (38.6ºC)?

• Private room.
• Room with a client who has biliary colic.
• Room with a client who is 3 days post operative hip

replacement.

• Room with a client who is in skeletal traction due to

broken femur.

• Private room.

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary?Select all that apply

• 3+ pedal edema
• CVP of 6 mm Hg
• One day weight loss of 2 pounds (0.9 kg)
• Purse-lip breathing
• Pale nail beds
• Urine output at 50 mL/hr

1, 4, 5

2. Incorrect: Normal CVP is 2-6 mm Hg. This CVP is within normal range so

treatment is effective.

3. Incorrect: Weight loss indicates that fluid is being removed

6. Incorrect: A urine output of 50mL/hour indicates that renal perfusion is

adequate.The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing?

• Honeymoon phase
• Tension-building phase
• Acute battering phase
• Remorse phase

2

• Correct: In the tension-building phase, minor physical or emotional abuse may

occur as well as verbal arguments. The victim feels growing tension and tries to control the situation.

1. Incorrect: The honeymoon phase is characterized by remorse with promises

never to hurt the victim again. The abuser is sorry and apologetic.

3. Incorrect: The acute battering phase includes the release of tension through

extreme physical violence. This is also called the explosion phase.

4. Incorrect: There is no remorse phase, but remorse is expressed during the

honeymoon phase. There are 3 phases: tension building, acute battering

(explosion) and honeymoon phase.

The OR nursing supervisor is notified by staff in the sterilization room that a foul odor has been noted. Upon inspecting the room, the nurse notes a small amount of sewage seeping up through the floor drain. What priority actions should the supervisor initiate?Select all that apply

• Evacuate staff from the room and lock the door.
• Tell staff to remove any equipment already sterilized.
• Report the incident to the administrative Chief

Executive Officer (CEO).

• Call maintenance to thoroughly clean the room.
• Initiate 'internal disaster protocols' immediately.

1, 3 & 5. Correct:

Raw sewage could expose staff to potential hepatitis A as well as other severe health problems. Leaking sewage presents the danger of methane gas formation.The nurse's initial action must be to evacuate all personnel from the room and lock, or seal off, the door until the proper authorized personnel are available.Because this situation could impact the functioning of the facility as well as staff/client health, the administrative CEO needs to be notified immediately.Sewage represents the potential for deadly complications, and therefore the situation is classified as an "internal disaster". Appropriate protocols should be initiated.

2. Incorrect: Any equipment in that room, even if sealed in bags, is no longer

considered sterile. Nothing should be removed from that room unless ordered so by the hospital CEO.

• Incorrect: This situation can be hazardous to both staff and clients, depending

on the location of sterilization room. Dealing with leaking sewage requires professional cleanup, along with evaluation by governmental or local authorities to locate and repair the source of the leak.Which signs and symptoms would concern the nurse if seen in a client post radical neck surgery?Select all that apply

• Decreased deep tendon reflexes
• Flaccid muscle tone
• Laryngeal stridor
• Muscle cramps
• Negative Trousseau's sign

3., & 4. Correct: Laryngeal stridor and muscle cramps are signs indicating that muscles are rigid and tight due to a low calcium level. Some of the parathyroids could have been removed resulting in hypocalcemia.

1. Incorrect: Decreased deep tendon reflexes would be seen with

hypermagnesemia and hypercalcemia because they act like sedatives.

2. Incorrect: Flaccid muscle tone is seen with hypermagnesemia and

hypercalcemia because they act like sedatives.

• Incorrect: A negative Trousseau's sign is a good thing. It would be positive if the

calcium level is low.A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis?

• pH - 7.46, PaCO2 - 30, HCO3 - 26
• pH - 7.45, PaCO2 - 35, HCO3 - 25
• pH - 7.36, PaCO2 - 43, HCO3 - 24
• pH - 7.43, PaCO2 - 31, HCO3 - 20
• Correct: This set of ABGs indicate compensated respiratory alkalosis. The pH is

normal, but on the alkalotic side of normal (normal 7.35-7.45; perfect is 7.4). The PaCO2 is low, indicating alkalosis, so it matches the alkalotic pH. The bicarb are low at 20 which indicates acidosis. The bicarb is low to get rid of base.Compensation has occurred.

• Incorrect: pH - 7.46, PaCO2 - 30, HCO3 - 26. The pH is high. The PaCOs is low.

The bicarb is normal. This is uncompensated respiratory alkalsosis.

• Incorrect: pH - 7.45, PaCO2 - 35, HCO3 - 25. All of these values are normal. No

acid base problem here.

3. Incorrect: pH - 7.36, PaCO2 - 43, HCO3 - 24. The pH is normal. The PaCO2 is

normal. The bicarb is normal.