NCLEX EXAM PREVIEW - HernandezOsuna89 Save NCLEX EXAM PREVIEW 110 terms

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Archer NCLEX Study Bank Question...152 terms Kimberly_Peacock47 Preview Archer NCLEX 65 terms HernandezOsuna89 Preview NCLEX 157 term Sob The nurse is caring for assigned patients; which of the following patients should the nurse identify is at highest risk for falling?

• 88-year-old admitted with a chest tube secondary to pneumothorax and history of dementia.
• 44-year-old admitted with heart failure, has a peripheral IV, and receiving IV furosemide.
• 33-year-old admitted with cholecystitis, has a peripheral IV, and is receiving IV hydromorphone.
• 28-year-old admitted with bacteremia, is receiving intravenous fluids via central line, and is diaphoretic.
• 88-year-old admitted with a chest tube secondary to pneumothorax and history of dementia.

The LPN is asked to check the client's respirations. Which of the following should the LPN perform?

• Place one hand over the patient's chest and count for 30 seconds.
• Count the respirations for one minute while simultaneously checking the client's pulse.
• Observe and count respirations for 30 seconds, then multiply by two without mentioning to the client that the respirations are being counted.
• If respirations are irregular, ask the patient to rest for 10 minutes, then reassess the respiratory rate.
• Count the respirations for one minute while simultaneously checking the client's pulse.

The son of a client with early Alzheimer's disease states, "I'm tired of hearing Dad talk about the all the time." What is the nurse's best response?

• "You should be more patient with your father and accepting of his disease."
• "He is quite anxious at this stage. Reliving the past helps him become calm again."
• "He has lost his short-term memory but can still remember events from long ago."
• "Just remind him when he repeats himself and that will reinforce better behavior."
• "He has lost his short-term memory but can still remember events from long ago."

You are caring for a 1 month-old infant who has a sudden cardiac arrest. Which pulse should you palpate to determine circulatory status?

• Brachial
• Femoral
• Carotid
• Popliteal
• Brachial

The nurse is visiting a patient who was recently prescribed antihypertensive medications. Which statement, if made by the patient, requires follow-up?

• "My pulse decreases after taking my metoprolol."
• "I started taking my furosemide right before I went to sleep."

C."1 am seasoning my foods without salt while on lisinopril."

• I wear my clonidine patch for seven days.
• "I started taking my furosemide right before I went to sleep."

Which of the following maternal infections can increase the risk of congenital heart defects in the fetus?

• Parainfluenza
• Adenovirus
• Rubella
• Measles
• Rubella

The nurse is caring for a patient with a Sengstaken-Blakemore tube. She performs her safety checks at the beginning of the shift and ensures which af the following priority items is readily avalable at the bedside?A.Trach kit

• Scissors

C.Obturator

• Yaunker
• Scissors

A diabetic patient receives ten units of Regular insulin and 20 units of NPH insulin each day after breakfast. After following the usual preparation steps for administering insulin, what should the nurse do next?

• Draw up NPH insulin first because it is clear.
• Either insulin can be drawn first as long as 30 units are given.
• Draw up Regular insulin first because it is clear.
• Administer each type of insulin separately for accuracy.
• Draw up Regular insulin first because it is clear.

The nurse is taking care of a client with Encopresis. Which of the following statements correctly describe Encopresis?

• Infrequent and hard to pass stools lasting greater than two weeks.
• Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.
• Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.
• Inability to pass stool due to fecal impaction.
• Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.

Right patient Right medication Right dose Right route Right time Right documentation Right reason Right response A patient is started on a daily amount of phenytoin 200 mg PO in two divided doses. What instruction from the nurse is incorrect?

• "You will need annual labs to determine the medication level in your body."
• "Remember never to skip a dose of this medication."
• "You need to increase your intake of vitamin D while taking this medication."
• "Maintain good oral hygiene and visit your dentist regularly."
• "You will need annual labs to determine the medication level in your body.

The nurse is administering digoxin to her 15-year old patient with congestive heart failure. She knows to verify the pulse rate before administering the medication and holds it for a pulse less than____.70 The LPN is reinforcing education to a client about modifiable risk factors and risk factors that not. Which of the following is most likely able to be corrected?

• Genetic predisposition
• Lifestyle choices
• Depression
• All of the above
• Lifestyle choices

The nurse is going over assigned patients for the shift. She knows that which of the following patients is most at risk for experiencing a fluid volume deficit?

• A patient with cirrhosis
• A patient with an ileostomy with a normal amount of output

C.A patient with a BUN of 32 and Cr 2.7

• A patient with DI and an NG tube to low intermittent wall suction
• A patient with DI and an NG tube to low intermittent wall suction

The patient with tuberculosis is now on isoniazid. Which laboratory test should be monitored at least monthly?

• PT and PTT

B. CBC

C. BUN

• Liver enzymes
• Liver enzymes

The nurse is caring for a patient who has pertussis. Which infection control precaution should the nurse implement?

• Wear a surgical mask prior to entry
• Provide disposable dishes for meals
• Keep the patient's room door closed
• Provide the patient with a portable fan
• Maintain negative air pressure
• Apply an N95 mask to the patient during transport.
• Place the patient in a room near the nurse's station.
• Wear a surgical mask prior to entry

After receiving report on the medical-surgical floor, which of the following clients should the nurse see first?

• A client with a respiratory rate of 24 and an oxygen saturation of 92%.
• A client that is scheduled for stomach surgery in two hours related to peptic ulcer disease.
• A client that is six hours post-op from a hysterectomy and is complaining of nausea. D. A client that had a cast applied two hours ago and now

has complaints of her arm feeling like it is "asleep".

• A client that had a cast applied two hours ago and now has complaints of her arm feeling like it is "asleep".

Which advice is most appropriate for a patient on neutropenic precautions who wants to learn ways to prevent infection?

• Only brush your teeth once a day or every other day.
• Avoid the use of tampons for menstrual periods.
• Do not let visitors within 10 feet.
• Wash hands after handling pets.
• Avoid the use of tampons for menstrual periods.
• A patient with hyperemesis gravidarum
• A patient in renal failure

C.A patient in diabetic ketoacidosis

• A patient with third degree burns
• A patient with hyperemesis gravidarum
• The patient should be counseled to increase their fiuid intake."
• "A 24-hour urine will be needed to confirm the diagnosis."
• "Risk factors include frequent intercourse and douching."
• "Cranberry concentrate may be used to prevent future infections."
• "A 24-hour urine will be needed to confirm the diagnosis." [46%]

The nurse is educating a new nurse starting on her unit about the causes of bacterial tonsillitis in children. She correctly explains that which of the following is the most common cause of bacterial tonsillitis.

• Group A beta hemolytic streptococcus
• Streptococcus pneumoniae
• Group B streptococcus
• Neisseria meningitidis
• Group A beta hemolytic streptococcus