NCLEX EXAM PREVIEW - kandykat1012 Save NCLEX-RN Exam Preview 113 terms

NCLEX EXAM PREVIEW

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NCLEX EXAM PREVIEW

110 terms Jason207171Preview NCLEX Teacher Tut The charge nurse has received a change-of-shift report on the following clients in labor. The charge nurse should ask a staff member to first see the client in the

• first stage of labor who has an oral temperature of 99.7° F (37.6° C)
• first stage of labor whose contractions are occurring every 30 seconds
• second stage of labor who has respirations of 26
• second stage of labor whose contractions are lasting for 60 seconds
• first stage of labor whose contractions are occurring every 30 seconds

Contractions should be no longer than 90 secs and no closer than 2 mins (120 secs) 90 secs is the duration, 2 mins is the frequency.

Rationale:

• Elevated temp is normal during labor
• Increased resps are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern
• Contractions shouldn't be longer than 90 secs, 60 secs is okay and normal

Second stage: 2-3 mins apart, 60-90 secs long, 10 cm dilated, strong pain

The nurse is observing a staff member caring for a client who has chickenpox.Which of the following actions by the staff member would require the nurse to intervene?

• placing the client in a private room with monitored negative air pressure
• placing a box of disposable face shields outside the client's room
• placing an alcohol-based hand rub in the client's room for hand hygiene
• placing a surgical mask on the client during transport out of the client's room
• placing a box of disposable face shields outside the client's room

disposable face masks are not suitable for airborne precautions

Rationale:

Varicella (chickenpox) is airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing surgical mask on client during transport are all correct interventions for Varicilla.

The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm shown in the electrocardiogram (ECG) strip below.

• BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)

Which of the following actions would be appropriate for the nurse to take? Select all that apply:

• Administer the client's prescribed beta blocker.
• Prepare for transcutaneous pacing.
• Instruct the client to perform the Valsalva maneuver.
• Begin chest compressions.
• Assess the client for angina.
• transcutaneous pacing
• external pacing that stimulates the ventricles to pump at a set rate
• Assess the client for angina
• Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Assessment of angina is

appropriate

Rationale:

• Beta blocker would further decrease HR
• Valsalva maneuver/Vagal stimulation would further decrease HR. (can be indicated for sinus Tachy)
• Chest compressions are for cardiac arrest

The nurse is planning care for a client with moderate Alzheimer's disease (AD).Which of the following interventions should the nurse include in the client's plan of care?

• Encourage the client to reminisce about happy memories.
• Confront the client when inappropriate or agitated behaviors occur.
• Administer to the client the cholinesterase inhibitor to reverse the course of AD.
• Provide the client with information about activity choices in the morning so the client can make plans for the day.
• Encourage the client to reminisce about happy memories.

Its possible for AD patients to retain long-term memories

Rationale:

• Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
• AD is irreversible
• In moderate AD, dementia has already progressed to where pt needs help with ADLs and planning daily activities. Asking them to plan can

frustrate them and cause distress.STRUCTURED pleasant activities that consider the persons likes and interests are the best.The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?

• "Use your hands and arms to support your body weight."
• "Wear slippers when ambulating with the crutches in your home."
• "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
• "Adjust the hand grips of the crutches so that your elbows are fully extended."
• "Use your hands and arms to support your body weight."

True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and paresthesias in wrists and hands

Rationales:

• Fall risk!
• Should be 6 in. in front and 6 in. lateral
• Elbows should be bent at 30 degree angle

The nurse has taught a client with multiple sclerosis (MS).Which of the following statements by the client would indicate a correct understanding of the teaching?

• "I will complete all of my household chores in the morning when I am well rested."
• "I have learned how to massage my bladder to help empty my bladder completely."
• "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
• "I should expect the blurred vision to resolve after I have received medications for several weeks."
• "I should expect the blurred vision to resolve after I have received medications for several weeks."

MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it quicker

Rationale:

• MS patients should not exert themselves too much at one time. Space out activities and allow time for rest.
• Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with it but are not the primary treatment
• Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked up and extra heat can stress your body into

overdrive The nurse has attended a staff education program about caring for clients who are receiving positive pressure mechanical ventilation. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

• "Clients should avoid range-of-motion (ROM) exercises until weaned from ventilation."
• "Clients may develop stress ulcers and gastrointestinal bleeding."
• "Clients will be chemically paralyzed to improve oxygenation."
• "Clients will experience diuresis and polyuria."
• "Clients may develop stress ulcers and gastrointestinal bleeding."

Rationale: Postive Pressure Ventilation may cause stress ulcers and GI bleeding because The charge nurse must transfer a female client from the medical-surgical unit to the maternity unit to make a bed available. It would be most appropriate for the nurse to transfer the client who is

• 28 years old, had a right mastectomy and has a closed-wound drainage system
• 49 years old, has diabetes mellitus (type 2) and has begun receiving insulin
• 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours
• 70 years old, has a fractured left tibia and had an external fixation device applied 48 hours ago
• 56 years old, has hepatitis C (HCV) and has been afebrile for 24 hours

The nurse has been made aware of the following client situations. The nurse should first assess the client with:

• heart failure who has a productive cough and is anxious
• regional enteritis (Crohn's disease) who is reporting cramping abdominal pain and diarrhea
• idiopathic thrombocytopenic purpura (ITP) who has petechiae on the trunk and is reporting heavy menses
• chronic obstructive pulmonary disease (COPD) who has dyspnea with exertion and is using accessory muscles to breathe
• heart failure who has a productive cough and is anxious

Productive cough (pink frothy sputum) indicates pulmonary edema, anxiety might be caused by decreased perfusion

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP?

• assisting a client with atrial fibrillation to shower
• checking the ability of a client to swallow water after a transesophageal echocardiogram (TEE)
• observing while a client with dysphagia begins a thickened liquid diet
• transporting a client with respiratory distress to the radiology department for a chest radiograph
• assisting a client with atrial fibrillation to shower

UAP can perform hygiene

Rationale:

Only nurses can assess. Transporting a client in respiratory arrest is not safe to delegate to a UAP The nurse has taken a nutritional history from parents of clients. It would be a priority for the nurse to follow up with the

• 5-month-old client whose only source of nutrition is 5 formula feedings daily
• 7-month-old client who eats several crackers as finger food
• 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal
• 1-year-old client whose typical food intake includes 4 breast-feedings and 3 servings of cooked vegetables, pears, or sliced cheese
• 9-month-old client whose typical daily diet includes 10 bottles of 2% milk, 1 cup of apple juice, and 3 servings of infant cereal

Rationale: Cows milk should be introduced at 12 months old. It doesn't provide the necessary nutrients and baby can develop iron deficiency The nurse is planning a staff education program about client privacy. Which of the following scenarios should the nurse include as an example of a violation of client privacy?

• discussing with an unlicensed assistive personnel (UAP) that the UAP's assigned client will require a smaller condom catheter
• sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED)
• responding to the call light of the client who is assigned to another nurse and needs assistance in the bathroom
• allowing a nursing student who has been assigned to the client to review the client's medical record
• sharing the client's blood alcohol level (BAL) test result with the police officer who brought the client to the emergency department (ED)

Rationale: PHI is permitted to be disclosed to police when PHI is needed to apprehend the perpetrator of a violent crime, suspect, or fugitive.The nurse has become aware of the following client situations. The nurse should first assess the client

• who had a right pneumonectomy 24 hours ago and is in the high-Fowler's position while lying on the right side
• with chronic obstructive pulmonary disease (COPD) who is using pursed-lip breathing and reporting hemoptysis
• who had a wedge resection of the left lung 24 hours ago and is sitting in the high-Fowler's position
• with heart failure who has a productive cough and is restless
• with heart failure who has a productive cough and is restless

Productive cough (pink frothy sputum) is indicative of pulmonary edema which is life-threatening. T(x) would be to improve cardiac output by placing client in high fowlers, O2, mechanical ventilation, meds