COMPLETE REVISION QUESTIONS

NCLEX's Safe & Effective Care Environment Management of Care

COMPLETE REVISION QUESTIONS

AND CORRECT DETAILED ANSWERS

(VERIFIED ANSWERS) ALREADY

GRADED A+

The nurse caring for a newborn diagnosed with transposition of the great vessels knows that which of the following interventions is a priority?

• Administer IV prostaglandin E1
• Record intake and output
• Administer IV furosemide
• Daily weights at the same time - Answer: Answer: 1

Rationale:

• Administer IV prostaglandin E1

It is essential that the ductus arteriosus be kept open to allow blood to mix. If the ductus arteriosus closes there will be no communication between oxygenated blood and deoxygenated blood resulting in extreme hypoxia.

• Record intake and output

Prostaglandin E1 should be given top priority because it is essential that the ductus arteriosus be kept open to allow blood to mix. If the ductus arteriosus closes there will be no communication between oxygenated blood and deoxygenated blood resulting in extreme hypoxia.

• Administer IV furosemide

Prostaglandin E1 should be given top priority because it is essential that the ductus arteriosus be kept open to allow blood to mix. Furosemide may be indicated if heart failure develops, but it would not be the first priority. 1 / 2

• Daily weights at the same time

Prostaglandin E1 should be given top priority because it is essential that the ductus arteriosus be kept open to allow blood to mix. Weighing the child is important to help identify fluid overload but would not be a top priority.A new nurse is learning how to triage and prioritize clients. The nurse has the following four clients waiting for a room and knows that the client with which of the following is the priority?

• New onset left sided weakness
• Injured hand from being slammed in a door
• Sharp RLQ abdominal pain 6/10
• Back and neck pain from an MVC - Answer: Answer: 1

Rationale:

• New onset left sided weakness

One-sided weakness, especially new onset, is concern for a stroke and should be evaluated immediately to rule out and/or begin treatment for stroke. This will require multiple resources and could progress to life threatening quickly. **Test-taking tip: you can only use the information you are given. We don't know if there are danger zone vitals for the abdominal pain client, or if the MVC client is able to walk or has any numbness - without that information, you cannot prioritize those clients over a possible stroke.

• Injured hand from being slammed in a door

This client is stable, though distal circulation should be monitored closely. It is not the priority at this time.

• Sharp RLQ abdominal pain 6/10

This client is stable at this time. They will need to be put in a room to evaluate for appendicitis, but the client with the stroke should be seen first.

• Back and neck pain from an MVC
• / 2