NCLEX PREP PASSING LEVEL

NCLEX PREP PASSING LEVEL

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ACLS: FINAL TEST QUESTIONS AND ...

50 terms princessdeb_Preview ACLS Final Exam 50 terms CNPalmer3Preview Chapter 7 - Professional Standards i...10 terms nili_siegel1Preview BLS 21 terms Irisc A family brings the client to the emergency department.The family reports the client had a sudden onset of left facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask?

• "What over-the-counter medications does your parent

take?"

• "What was your parent doing when the symptoms

began?"

• "When did you first notice the onset of the symptoms?"
• "Does your parent have a history of high blood

pressure?" 1) not the most important question to ask; may be important to determine if any medications increase the risk of bleeding 2) hemorrhagic stroke may be precipitated by strenuous activity and an increase in blood pressure 3) CORRECT — circulation, current; important to determine when symptoms began if thrombolytic therapy is to be used 4) circulation, history; high blood pressure is a common risk factor for all types of stroke; more important to deal with the here and now The nurse meets with the parent of a 13-year-old boy in the pediatric health care provider's office. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct?

• "Your son might have attention deficit hyperactivity

disorder."

• "I'll talk with the health care provider about assessing

for subtle motor dysfunction. "

• "Your son's clumsiness is expected at this age."
• "This may be an early sign of depression."

1) false statement about uncoordination in 13-year-old males; eliminate 2) false statement about uncoordination in 13-year-old males; eliminate 3) CORRECT— true statement about uncoordination in 13-year-old males 4) false statement about uncoordination in 13-year-old males; eliminate

The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include in the instructions?Select all that apply.

• "We will move you to the operating room where the

test is always performed."

• "The bone in the front of your chest will be used for the

biopsy specimen."

• "A tight pressure dressing will be placed over the test

site after the procedure."

• "You will not feel any discomfort as the local anesthetic

is injected."

• "There is a risk of bleeding, so we will monitor the test

site frequently." 1) bone marrow aspiration and biopsy may be done in client room or treatment room; OR not required 2) the sternum may be used for bone marrow aspiration, but not biopsy; not enough marrow available in sternum for biopsy 3) CORRECT — pressure dressing applied to reduce the risk of bleeding; this is a true answer 4) will feel some stinging and discomfort 5) CORRECT — site will be monitored frequently, especially if there is a risk of bleeding The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches the client, the client does not look at the nurse. Which is the most appropriate question for the nurse to ask?

• "Sleep problems are common during times of stress.

Have you had difficulty sleeping?"

• "Tell me what you know about your diagnosis and the

treatment you will receive."

• "How would you describe your overall health status up

to this time of your life?"

• "How have you handled any health problems you

experienced in the past?" 1) yes-no answer; excessive sleep or insomnia may be seen with poor coping; can keep for consideration 2) CORRECT — open-ended; it is most important to determine the client's perception of the health problem 3) does not address the concern; overall health status may influence adaptive coping; not most important 4) more important to deal with the here and now; does not address current problem The nurse cares for the client immediately after arrival in the emergency department. Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action the nurse should take?

• Determine Glasgow Coma Scale (GCS) score.
• Assess bilateral blood pressure.
• Check bilateral pupillary response to light.
• Determine oxygen saturation levels.

1) GCS is used to assess clients diagnosed with head trauma; airway, breathing, circulation and neurological status; very broad 2) circulation; airway is priority; increase in arterial carbon dioxide levels will increase intracranial pressure 3) not an A, B, or C answer; neurological status assessed after airway, breathing, and circulation 4) CORRECT — airway assessed first

At a rehabilitation center for spinal-cord-injured (SCI) clients, the nurse conducts an orientation session for a group of nursing assistive personnel (NAP). Which statement is most important for the nurse to include?

• "The clients may appear angry at times."
• "Obtain the client's permission before touching the

client."

• "Most clients arrive believing they will walk out of

here."

• "Personnel in this environment often need counseling."

1) psychological; eliminate 2) CORRECT — physical 3) psychological; eliminate 4) psychological; eliminate The home care nurse instructs a client diagnosed with multiple sclerosis. The client states " I have poor concentration and difficulty pronouncing words". The nurse notes that the client's speech is slow and slurred.Which statement, if made by the client to the nurse, indicates further teaching is necessary?

• "I will sit up straight when I talk and will feel confident."
• "I will turn off the TV when speaking and look at the

person with whom I am talking."

• "During a conversation, I will carefully build up to my

most important points."

• "If words fail me, I will draw a picture."

1) true statement for communicating with MS; eliminate 2) true statement for communicating with MS; eliminate 3) CORRECT— false statement for communicating with MS 4) true statement for communicating with MS; eliminate The client diagnosed with malnutrition is prescribed continuous enteral feedings through a gastrostomy tube.Which actions will the nurse include in the plan of care?Select all that apply.

• Cover the insertion site with an adhesive bandage.
• Add 8 hours of feeding to the bag at a time.
• Rotate the gastrostomy tube 360 degrees once daily.
• Auscultate for whoosh of air through the gastrostomy

tube.

• Check for slight in-and-out movement of the

gastrostomy tube.1) gastrostomy insertion site should be covered with sterile bandage to reduce the risk of infection 2) only 4 hours of enteral feeding should be added to bag to reduce the risk of bacterial contamination 3) CORRECT — should be rotated 360 degrees daily to reduce the risk of skin irritation and breakdown 4) insertion of air is not recommended for gastrostomy tube placement assessment; this action would not be placed in the plan of care 5) CORRECT — slight in-and-out movement indicates that the gastrostomy tube is not embedded in the wall of stomach

The client diagnosed with a stroke is admitted to a rehabilitation center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left when sitting in a chair or wheelchair. Which is the most appropriate action for the nurse to take?

• Place the client's favorite watch on the left wrist.
• Provide a written list for client to follow during morning

care.

• Instruct the client to choose a dress for the day.
• Position the client so the right side faces the door of

the room.1) psychosocial; client may ignore watch; should be considered because it may encourage client to look at affected side of body; safety is main concern 2) psychosocial; verbal instructions with short sentences are used; client may have short attention span 3) psychosocial; having the client choose a dress is an appropriate implementation; positioning is the priority 4) CORRECT — physical; has right-sided stroke with left-sided unilateral neglect syndrome; client cannot see out of left side of both eyes; position client for best vision so the client is not scared or upset by approaching people The client is brought to the emergency department by friends. The client reports a dry mouth, frequent urination, extreme thirst, and no fluid intake for the last 8 hours. The friends report the client may not have taken insulin during the last couple of days. The nurse reviews orders from the health care provider. Which order should the nurse implement first?

• Administer 20 mEq potassium chloride orally.
• Begin regular insulin at 0.1 units/kg/hour.
• Obtain a 12-lead electrocardiogram.
• Begin infusion of 0.9 % NaCl at 1 liter per hour.

1) implementation, physical, circulation; mild to moderate hyperkalemia seen during initial phase of diabetic ketoacidosis; potassium chloride not indicated at this time, but will be administered later when potassium moves into the cells during insulin administration 2) implementation, physical, not A, B, or C; eliminate; indicated, but priority is to restore fluid volume 3) assessment, is this needed; no, eliminate; may be indicated to detect dysrhythmias related to potassium imbalance; not priority 4) CORRECT — implementation, physical, circulation; priority is to replace fluid volume; during DKA osmotic diuresis occurs and client at significant risk for fluid volume deficit The nurse reviews the chart of the client recently diagnosed with Guillain-Barré syndrome. The client has flaccid paralysis of both legs, a history of coronary artery bypass surgery 3 weeks ago, and a 20-year history of hypertension and hypercholesteremia. The client was recently diagnosed with type 2 diabetes. The nurse prepares to apply antiembolism stockings to both legs.Which priority action does the nurse take?

• Assess for bilateral pretibial edema.
• Palpate both calves for pain.
• Ask the client the reason for application of

antiembolism stockings.

• Palpate bilateral pedal pulse strength.

1) physical, circulation; some edema expected with immobility; purpose of antiembolism stockings may be to reduce edema 2) psychosocial; eliminate; venous thromboembolism is contraindication for antiembolism stockings; client may not have calf pain with venous thromboembolism in the deeper veins 3) psychosocial; eliminate; understanding the reason for a treatment are important but do not take priority over physical assessments 4) CORRECT — physical, circulation; best indication of peripheral arterial disease and circulation to extremities; decreased circulation is contraindication for antiembolism stockings