NCLEX - Readiness assessment questions

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Archer 67 terms lilnu Hyphemablood in the anterior chamber of the eye The nurse is caring for a child who is lethargic and with a capillary blood glucose of 46 mg/dL (2.55 mmol/L) [70- 110 mg/dL, 4.0-11.0 mmol/L]. Which essential action should the nurse take?

• Obtain another capillary blood glucose
• Encourage the consumption of 120 mL of fruit juice
• Administer prescribed glucagon SubQ
• Perform a Glasgow Coma Scale (GCS) assessment

C Administer prescribed glucagon SubQ The client is lethargic and hypoglycemic. This is quite concerning and calls for the nurse to immediately administer a parenteral treatment (either glucagon SubQ/IM) or Dextrose 50% via intravenous push (IVP). While this blood glucose may respond to mouth (PO) foods and fluids, the client is lethargic and should not be fed because of the risk of aspiration.The nurse teaches a pregnant client with the hepatitis C virus (HCV). Which of the following statements by the client would require follow-up? Select all that apply.

• I will be unable to breastfeed my baby.
• "I will have to deliver my baby by cesarean to decrease

the risk of transmission."

• I can continue my antiviral drugs while I am pregnant."
• My baby will need to be isolated while in the hospital.

It may be several months before I know if my baby has hepatitis C." A, B, C & D These client statements require follow-up by the nurse because they are not accurate. Hepatitis C is a blood-borne pathogen and is not transmitted in breast milk. It is safe for a woman to breastfeed if she has the hepatitis C virus. If her nipples should crack and start to bleed, breastfeeding should be halted. Vaginal delivery is approved for a client with HCV. Cesarean delivery is not advised because of the increased risk of blood exposure unless indicated for other reasons. Unlike HIV infection, antiviral drugs for HCV are unsafe during pregnancy and must be suspended during the pregnancy. Isolation for an individual with hepatitis C is unnecessary (standard precautions are used).

The nurse supervises a nursing student administering a purified protein derivative (PPD) skin test. Which action by the student requires follow-up by the nurse?A.Inserts the needle, bevel up at a 15-degree angle B.Instructs the client that the test will be read in 48-72 hours C.Selects a site 3 to 4 finger widths below the antecubital space D.Administers the test using a 20-gauge needle, 2 inches long .Administers the test using a 20-gauge needle, 2 inches long When administering a PPD, the nurse should administer the test intradermal at an angle of 15-degrees. The appropriate gauge and length of the needle should be 25- to 27-gauge, ½- to 5⁄8-inch.These observations do not require follow-up because these observations are appropriate. It is appropriate for the nurse to administer this test at an angle of 15- degrees with the bevel up. PPD testing is read within 48-72 hours and is administered 3 to 4 finger widths below the antecubital space.The perinatal nurse is caring for a client experiencing suspected placental abruption. Which of the following signs and symptoms would be expected assessment findings for this client?Painless vaginal bleeding Painful vaginal bleeding Hypotension Rigid abdomen Fetal tachycardia Painful vaginal bleeding, Hypotension, Rigid abdomen B is correct. A significant amount of vaginal bleeding is a prominent sign of placental abruption. The bleeding occurs due to the placenta separating from the wall of the uterus. The bleeding is usually painful.C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of placental abruption. When the mother loses large amounts of blood, her blood pressure will drop, potentially resulting in hypovolemic shock. This hypovolemia is treated with IV fluids and blood products such as PRBCs.D is correct. A rigid, board-like abdomen is a sign of placental abruption. This is also due to massive blood loss and internal bleeding. As the placenta separates from the womb's wall, blood accumulates in the abdomen, causing it to become rigid and board-like.The nurse is instructing the parents of a child with asthma about a peak flow meter. Which statement, if made by the parents, would indicate effective teaching?."Before use, I should put the sliding marker at the top of the numbered scale." B."I should have my child sit at a 45-degree angle while performing this procedure." C."My child should inhale as quickly as they can through the mouthpiece." D."I should record the highest of the three readings." i should record the highest 3 readings The child's highest reading out of three times should be recorded (not the average). It is important that between each measurement, a 30-second rest is taken by the child.The nurse performs a physical assessment on a client and observes a tremor in the client's hand when their arm is extended. The nurse understands that this finding is consistent with which of the following?

• rheumatic fever

B.End-stage renal disease C.Neuroleptic Malignant Syndrome (NMS) D.Human Immunodeficiency Virus (HIV) End-stage renal disease Asterixis is a hand flapping tremor that may be elicited by having the client close their eyes, extend their arms, dorsiflex their wrist, and spread their fingers. End- stage renal disease causes azotemia and may trigger this unilateral or bilateral tremor in end-stage renal disease. While this tremor is poorly understood, it is likely the accumulation of nitrogenous waste that contributes to the development of this action. This tremor has also been associated with moderate to severe hepatic encephalopathy.

The nurse is caring for a four-year-old child. While developing a plan of care, the nurse recognizes the child is in which stage of Erikson's stages of psychosocial development?A.Initiative vs. Guilt B.Autonomy vs. Shame and Doubt C.Industry vs. Inferiority D.Trust vs. Mistrust initiate vs guilt Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your four-year-old client. In Initiative vs.Guilt, children assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval and may feel a sense of guilt.A client who smokes cigarettes has a new prescription for varenicline. The nurse instructs the client to take this medication how many days before their planned quit date?A.14 days B.7 days C.2 days D.21 days

• days

Varenicline is a medication intended to assist an individual with smoking cessation.This medication should be started seven days before the planned quit date and gradually increased in dose. The medication may be prescribed for twelve weeks to ensure appropriate abstinence.The nurse is caring for a pregnant client at 34 weeks gestation. The client reports severe itching on her palms and soles, along with dark urine, and scleral jaundice. Lab results show elevated serum bile acids and alanine aminotransferase (ALT). The nurse suspects which of the following?A.Eclampsia B.Gestational diabetes mellitus C.Cholestasis of pregnancy D.Acute fatty liver of pregnancy cholestasis of pregnancy Cholestasis of pregnancy, also known as intrahepatic cholestasis of pregnancy (ICP), is a liver disorder characterized by impaired bile flow during pregnancy. It typically presents with intense pruritus, especially on the palms and soles, along with jaundice, dark urine, and pale stools. Elevated serum bile acids and liver enzymes, such as alanine aminotransferase (ALT), are commonly observed in laboratory tests of individuals with cholestasis of pregnancy.What are the expected interventions for a patietn with ahemothorax and Hx of hemophilia A replace factor IIIV tube thoracostomy (chest tube) - Supine with HOB 30-45 The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?' A.Positive pressure ventilation B.Pericardiocentesis C.Echocardiography D.0.9% saline bolus

A. PPV

Positive pressure ventilation (PPV) would be detrimental to a client experiencing cardiac tamponade. This order requires follow-up. PPV increases intrathoracic pressure, which decreases venous return to the heart. This reduction of venous return impairs ventricular filling and reduces cardiac output. This would be detrimental in a cardiac tamponade where the cardiac output is already impaired.