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NCLEX EXAM PREVIEW

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NCLEX EXAM PREVIEW

110 terms Jason207171Preview NCSBN 408 term AN 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 99.7F (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

Rationale:

• Elevated temperature is normal during labor.
• Increased respirations are normal during labor "pant-pant-blow" "hee-hee-hoo" breathing pattern.
• Contractions shouldn't be longer than 90 seconds, 60 seconds is okay and normal. Second stage: 2-3 minutes apart, 60-90 seconds long,

10cm 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.

Rationale:

Varicella AKA chicken pox is an airborne precaution. Private, negative pressure room, universal precautions (hand sanitizer in room) and placing a surgical mask on client during transport are all correct interventions for varicella.

• Prepare for transcutaneous pacing.

& 5. Assess the client for angina.

Rationale:

• Beta Blockers would further decrease HR.
• External pacing stimulates the ventricles to pump at a set rate.
• Valsalva maneuver would further decrease HR.
• Chest compressions are for cardiac arrest.
• Angina (Chest pain) can be caused by both tachycardia (most common) and bradycardia (rare but can happen). Therefore, assessment of

angina is appropriate.The nurse is caring for a client who reports feeling faint and is experiencing the cardiac rhythm shown in the electrocardiogram (ECG) strip below.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.
• Encourage the client to reminisce about happy memories.

Rationale:

• Is correct because it is possible for AD patients to retain long-term memories.
• Redirect is protocol for dementia. Don't confront, they can't learn.
• AD is irreversible.
• In the moderate AD, dementia has already progressed to where the patient needs help with ADL's & planning daily activities. Asking them to

plan can frustrate them & cause distress. Structured, pleasant activities that consider the person's likes & interests are the best.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.

• "Use your hands and arms to support your body weight."

Rationale:

• Is true, but watch out if it isn't 2-3 finger-widths, because crutch paralysis can occur. S/S: Paresis & Paresthesias in wrist & hands.
• Is a fall risk.
• Crutches should be 6 inches in front & 6 inches lateral.
• Elbow should be bent at a 30 degree angle.

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 12inch (30cm) in front of your feet while standing."
• "Adjust the hand grips of the crutches so that your elbows are fully extended."
• "I should expect the blurred vision to resolve after I have received medications for several weeks."

Rationale:

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

• MS patients should not exert themselves too much at one time. Space out activities & 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 messed up and extra heat can stress the body into

overdrive.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."

Highlight:

"Loss of appetite" "Abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week." "Client states, "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." "Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air.

Rationale:

Loss of appetite may indicate an underlying medical condition or infection.The intensity of abdominal pain requires evaluation to determine the cause.Trauma to the abdomen can cause internal injuries that need to be assessed to ensure no significant damage or complications.The nurse in the emergency department (ED) is caring for a 41-year-old male client.Highlight the findings below that would require follow-up.(See Picture)

Answer:

Bowel obstruction: Appetite, Bowel Pattern, Gastrointestinal Symptoms.

Appendicitis: Pain level.

Ruptured Spleen: Pain level.

The nurse in the emergency department is caring for a 41-year-old male client.

Nurse's Notes:

11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions.For each assessment finding below, click to specify if the finding is consistent with the disease process of bowel obstruction, appendicitis, or ruptured spleen. Each finding may support more than 1 disease process.

Answer:

•Anemia •Peritonitis •Septic Shock The nurse in the emergency department is caring for a 41-year-old male client.

Nurse's Notes:

11:00: Client reports nausea, loss of appetite, vomiting, fever, and constipation for the past 2 weeks and abdominal pain rated 7/10 on the Numerical Rating Scale for 1 week. Client states "The abdominal pain started after my 7-year-old child accidentally kicked me in the stomach." Client plays soccer with the child once a week. Vital signs: T 103.4 F (39.7 C), P 92, RR 22, BP 130/86, pulse oximetry reading 98% on room air. No significant past medical or surgical history. Body mass index (BMI) 32. Drinks alcohol only during social occasions, usually 3 beverages. Smokes cigarettes during social occasions.Select the 3 complications the client is at risk for developing.•Anemia •Peritonitis •Septic Shock •Hypovolemia •Dysrhythmias •Cardiac Arrest