NCLEX PN ARCHER REVIEW

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NCLEX PN ARCHER REVIEW

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• You're providing discharge teaching to a patient who

was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning

signs verbalized by the patient:

• Easily fatigued with physical activity
• Reduced peak flow meter reading
• Chest retractions
• Cyanosis
• Wheezing with activity
• Nighttime coughing
• No relief with short-acting bronchodilator inhaler

A,B,E,F

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

• Stridor
• Crackles
• Wheezes
• Diminished
• Wheezes

Rational: asthma is a respiratory disorder characterized by recurrent episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructive or narrow lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue were poor oxygen exchange is occurring.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

• Right side
• Low-Fowler's
• High-Fowler's
• Supine with the head flat
• High-Fowler's

Rationale: during insertion of an NG tube, the client is placed in a sitting or high Fowlers position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit.A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

• Lying in bed on the affected side
• Lying in bed on the unaffected side
• Sims position with the head of the bed flat
• Prone with the head turned to the side and supported

by pillow

• Lying in bed on the unaffected side

Rationale: to facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45° The nurse creates a plan of care for a patient with deep vein thrombosis. Which client position or activity in the plans should be included?

• Out of bed activities as desired
• Bedrest with the affected extremity kept flat
• Bedrest with elevation of the affected extremity
• Bedrest with the affected extremity in a dependent

position

• Bedrest with elevation of the affected extremity

Rationale: for the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which intern relieves Edema and pain.The nurse is caring for a client who was one day post operative for a total hip replacement. Which is the best position in which the nurse should place the client?

• Head elevated lying on the operative side
• On the non-operative side with legs abducted
• Side lying with the affected leg internally rotated
• Side lying with the affected leg externally rotated
• On the non-operative side with legs abducted

Rationale: positioning after a total hip replacement depends on the surgical

techniques used, the method of implantation, the prosthesis, and the primary healthcare providers preference. Abduction is maintained when the client is in a supine position or positioned on the non-operative side. Internal and X ternal rotation, adduction, or lying on the operative side is avoided to prevent displacement of the prosthesis The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?

• Left Sims position
• Right Sims position
• On the left side of the body, with the head of the bed

elevated 45°

• On the right side of the body, with the head of the bed

elevated 45°

• Left Sims position

Rationale: for administering an enema, the client is placed in the left Sims position so that the enema solution can flow by gravity in the natural direction of the colon.

The nurse has just released the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

• Urinary output of 20mL/hr
• Temperature of 37.6°C (99.6°F)
• Blood pressure of 100/70 mm Hg
• Serous drainage on the surgical dressing
• Urinary output of 20mL/ hr

Rationale: urine output should be maintained at a minimum of 30mL/hr. An output

of less than 30 mL for two consecutive hours should be reported to the surgeon.A temperature higher than 100°F or lower than 97°F in a failing systolic blood pressure, lower than 90, are usually considered reportable immediately. Serous drainage is normal.The nurse is teaching a client about coughing and deep breathing techniques to prevent a postoperative complication. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

• "Use of an incentive spirometer will help prevent

pneumonia"

• "Close monitoring of your oxygen saturation will detect

hypoxemia"

• "Administration of intravenous fluids will prevent or

treat fluid imbalance"

• "Early ambulation and administration of blood thinners

will prevent pulmonary embolism"

• "Use of an incentive spirometer will help prevent pneumonia"

Rationale: postoperative respiratory problems are atelectasis, pneumonia, and

pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an in adequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep breathing techniques A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

• Obtain a court order for the surgery
• Have the charge nurse sign the informed consent

immediately

• Send the client to surgery without the consent form

being signed

• Obtain a telephone consent from a family member

following agency policy

• Obtain a telephone consent from a family member following agency policy

Rationale: every effort should be made to obtain permission from a responsible

family member to perform surgery of the client is unable to sign the consent form.A telephone consent must be witnessed by two persons who hear the family members oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained.The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

• Avoid oral hygiene and rinsing with mouthwash
• Verify that the client has not eaten for the last 24 hours
• Have the client void immediately before going to

surgery

• Report immediately any slight increase in blood

pressure or pulse

• Have a client void immediately before going to surgery

Rationale: the nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common as a result of anxiety

A pre-operative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

• " If it's any help, everyone is nervous before surgery"
• " I will be happy to explain the entire surgical

procedure to you"

• "Can you share with me what you've been told about

your surgery?"

• "Let me tell you about the carrier you'll receive after

surgery and amount of pain you can anticipate"

• "Can you share with me what you've been told about your surgery?"

Rationale: explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth perioperative experience.The nurse is conducting perioperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

• Inhale as rapidly as possible
• Keep a loose seal between the lips and the

mouthpiece

• After maximum inspiration, hold the breath for 15

seconds and exhale

• The best results are achieved when sitting up or with a

head of the bed elevated 45 to 90°

• The best results are achieved sitting up or with the head of the bed elevated 45

to 90°

Rationale: for optimal long expansion with the incentive spirometer, the client

should assume the semi Fowler's or high Fowlers position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for five seconds before exhaling slowly The nurse has conducted perioperative teaching for a client scheduled for surgery in one week. The client has a history of arthritis and has been taking acestylsalicylic acid. The nurse determines that the client needs additional teaching at the client makes which statement?

• " aspirin can cause bleeding after surgery"
• " aspirin can cause my ability to clot blood to be

abnormal"

• " I need to continue to take the aspirin until the day of

surgery"

• " I need to check with my doctor about the need to

stop aspirin before the scheduled surgery"

• " I need to continue to take my aspirin until the day of surgery"

Rationale: antiplatelets alter normal clotting factors and increase the risk of

bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery.The nurse assesses a clients surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

• Red, hard skin
• Serous drainage
• Purulent drainage
• Warm, tender skin
• Serous drainage

Rationale: serous drainage is an expected finding at a surgical site. The other

options indicate signs of wound infection