NCLEX® Readiness

NCLEX® Readiness 13 studiers today Leave the first rating Students also studied Terms in this set (35) Science MedicineNursing Save Introduction to NCLEX Readiness -- ...20 terms CRN_0814Preview Introduction to NCLEX Readiness -- ...20 terms CRN_0814Preview Dosage Calculations - Part 1 20 terms sommertimesithelps Preview Nclex r 234 term jose Assessment Findings The nurse admits a client into the emergency department with shortness of breath, chest tightness, and wheezing.The client is barely able to complete a sentence, but the nurse learns that the client has a history of asthma. The client tried a rescue inhaler but “it did not work.” The client was coughing a lot but then struggled to cough.The nurse initiates the prescribed albuterol nebulizer.For each potential assessment finding, click to specify whether the finding indicates a potential improvement, signals a worsening condition, or is unrelated to the condition of the client after completion of the nebulizer treatment.​ Potential Improvement Lower pitch to expiratory wheeze Client able to complete sentences Increased coughing with nebulizer treatment Worsening Condition No audible breath sounds Client is restless Unrelated Mist stops coming from the nebulizer after 10 minutes Client reports increased thirst An albuterol nebulizer treatment is needed by some clients with asthma when they have an asthmatic attack that does not respond to the use of a rescue inhaler.A lower pitch to the wheeze means the airways are starting to open more, which means more air is moving through the airways. The client is not completely open since a wheeze is still present, but it does show an improvement. The client being able to cough some again and being able to complete sentences shows there is improvement after the treatment.Lack of audible breath sounds and restlessness are indications of a worsening condition as they indicate no air movement and hypoxia. Mist will stop coming from the nebulizer end when all the solution has been used up, which is about 5– 15 minutes after starting the treatment. Gently tapping the sides of the nebulizer container will help ensure that all medication has been aerosolized before turning off the machine. The completion of the treatment does not indicate a change in the condition itself. Thirst after an asthma attack is not an indicator of improvement nor a sign of worsening of the attack. Open-mouth breathing can be the reason for the increased thirst.

Priority Medications The nurse reviews discharge medications with a client.While explaining the new medications, the client asks if they can have one glass of wine at a wedding in the coming week. After reviewing the client's information, highlight the priority medication in the electronic health record (EHR) that indicates the client needs to avoid alcohol consumption.​ Discharge medications include fluticasone for environmental allergies. For infection, take metronidazole

• tablet twice a day for 7 days. Also, take amoxicillin 1

capsule three times a day for 14 days. ​ metronidazole Metronidazole is an antibiotic used to treat certain types of bacterial and parasitic infections. Drinking alcohol with metronidazole is known to cause abdominal cramping, headache, vomiting, and seizures.Alcohol will not stop amoxicillin or fluticasone from working if taken in moderation.Nursing Actions Vital Signs 4/4 Temp 97.2 °F ​(36.2 °C) HR 98 RR 18 BP 144/88 mmHg Pulse Oximetry 95% O2 RA Laboratory Results 4/4 Hemoglobin 7.8 g/dL (11.6–15 g/dL) Blood urea nitrogen 44 mg/dL (8–20 mg/dL) Creatinine 4.1 mg/dL (0.6–1.2 mg/dL) Glucose 142 mg/dL (70–100 mg/dL) Potassium 5.3 mEq/L (3.5–5.0 mEq/L) The nurse receives a hand-off report for a client scheduled for dialysis in two hours. After reviewing the electronic health record (EHR), which actions should the nurse take? Select all that apply.

• Administer the first of 2 units of prescribed packed red

blood cells.

• Hold the prescribed dose of sodium polystyrene

sulfonate by mouth daily.

• Hold the prescribed IV antibiotic ordered every 6

hours, due now.

• Deliver the prescribed dose of NPH insulin 5 units

subcutaneously.

• Hold the prescribed dose of lisinopril 20 mg by mouth

daily.

• Hold the prescribed dose of sodium polystyrene sulfonate by mouth daily.
• Hold the prescribed IV antibiotic ordered every 6 hours, due now.
• Deliver the prescribed dose of NPH insulin 5 units subcutaneously.
• Hold the prescribed dose of lisinopril 20 mg by mouth daily.

The nurse should hold the blood pressure medication, antibiotics, and sodium polystyrene sulfonate, since dialysis is scheduled in 2 hours and the medications will be removed during the process. Potassium will be reduced during dialysis, so getting the client dialyzed is a priority over polystyrene administration. It is safe for the nurse to deliver the insulin as the client can eat before and during dialysis.The blood is best given during dialysis so that the client does not experience fluid overload.

Acetaminophen Overdose The nurse reviews the electronic health record (EHR) of a 16-year-old client admitted to the pediatric unit for treatment following an overdose of acetaminophen. In what order should the nurse perform these prescriptions, from first to last?

• Insert peripheral venous access device
• Normal saline 100 mL bolus
• N-acetylcysteine infusion 150 mg/kg over one hour
• N-acetylcysteine infusion 12.5 mg/kg over four hours
• N-acetylcysteine infusion 6.25 mg/kg over sixteen hours
• Clear liquid diet as tolerated

First, the nurse should insert the peripheral venous access device. The normal saline bolus should be administered before N-acetylcysteine because that medication will be delivered continuously over a longer period. A clear liquid diet is the lowest priority after treatment of the client's condition has been initiated.The nurse should also obtain acetaminophen level now and every eight hours.Managing Heparin Administration The nurse cares for a client with pulmonary emboli receiving intravenous (IV) heparin therapy per the facility’s heparin protocol. The client weighs 100 kg. The infusion was initiated at a starting rate of 18 units/kg/hr and has been running for 6 hours. The hanging heparin bag is 25,000 units in 250 mL D5W. The nurse receives the client’s current anti-Xa value and finds it is 0.8 units/milliliter. Before answering this question, review the heparin titration protocol.​ For each potential nursing action, click to specify whether the intervention is indicated or not indicated for the care of the client at this time.​ Indicated Instruct the lab to draw an anti-Xa level in 6 hours Reprogram the pump to run at 17 mL/hour Assess the client for petechiae and bruising Assess the integrity of the IV site Not Indicated Bolus the client with 4000 units of heparin Turn off the IV pump Administer protamine sulfate as an antidote Ask the client if unilateral leg pain is present The nurse must recognize that the high anti-Xa level means that the client is getting too much heparin and the infusion rate needs to be slowed down according to the protocol. The protocol for 0.8 units/mL indicates that there is no bolus, the IV infusion is not stopped, and the running infusion needs to be decreased by 1 unit/kg/hour. The current rate is running at 18 units/kg/hour (18 mL/hr), so it needs to be changed to 17 units/kg/hr (17 mL/hr). The protocol dictates that after the rate change the nurse should schedule another anti-Xa lab to be drawn in 6 hours. Additionally, the nurse must understand that heparin is an anticoagulant; therefore, when heparin is having an increased effect, the nurse should be alert to signs/symptoms of bleeding in the client. The nurse should check the client for petechiae and new bruises as well as check if there is bleeding around the IV site.Determining the presence of unilateral leg pain is not as high a priority as the client is at risk of bleeding more than new clot formation currently. Assessment of the anti-Xa labs provides a more accurate assessment of the heparin activity within the body and requires fewer dosage adjustments to achieve and maintain a therapeutic range as compared with the previous aPTT test that was used in heparin titration. The typical goal is to maintain anti-Xa levels between 0.3–0.7 units/mL, but this is based on client need and indication for use.

Administering Chemotherapeutic Agents The nurse cares for a client receiving chemotherapy for leukemia. What actions should the nurse take when preparing and administering a vesicant agent? Select all that apply.​

• Place used supplies and protective equipment in the

regular trash.

• Check for blood return prior to administration.
• Infuse an antiemetic medication through the same line

as the chemotherapy.

• Use a central line instead of a peripheral line.
• Have a second qualified nurse verify the medication

with the primary nurse.

• Place absorbent pads underneath the lines when

initiating the infusion.

• Wear personal protective equipment when handling

the lines.

• Monitor for erythema, pus, red streaks, or bruising at

the line site.

• Check for blood return prior to administration.
• Use a central line instead of a peripheral line.
• Have a second qualified nurse verify the medication with the primary nurse.
• Place absorbent pads underneath the lines when initiating the infusion.
• Wear personal protective equipment when handling the lines.
• Monitor for erythema, pus, red streaks, or bruising at the line site.

A central line or port should be used for intravenous chemotherapy as peripheral lines are easily damaged from the consistency of the chemotherapy. The nurse should verify patency by checking for blood return in the line prior to the administration of chemotherapeutic agents. If infiltration of an IV occurs during the delivery of a non-vesicant, it can irritate the surrounding tissue. Extravasation from the delivery of a vesicant agent can erode and cause permanent damage to tissues. The nurse should watch for signs of irritation and extravasation on the client’s skin such as redness, streaking, bruising, and pus. A second qualified nurse should verify the medication just prior to administration. When administering the chemotherapy, a closed, needleless system is used, and there should be a dedicated line so no other medications are infused in that line. Nurses should protect themselves with double gloves, goggles, and a gown when handling chemotherapeutic agents. The nurse should keep a spill kit near the bedside. The nurse should discard items used during the infusion into a dedicated container for chemotherapy waste, and not in the regular trash.Reviewing Provider Prescriptions The nurse receives a client as a new admission. The client is experiencing a sickle cell crisis. After reviewing the provider's prescriptions, select the row from the provider’s prescription that indicates the need to contact the healthcare provider for clarification.​ Provider Prescriptions 6/5 @ 1245

• Morphine 1 mg by mouth every 4 hours as needed for

pain greater than 5/10​

• Hydroxyurea 35 mg/kg to be administered by mouth

on June 12 if client is still in the hospital​

• Oxygen via nasal canula to keep O2 Sat greater than

92%​

• Infuse D5W intravenously at 125 mL/hour ​

5. Diet: Regular – as tolerated. Increased fluid intake ​

• Occupational and physical therapy consultations ​
• Notify on-call hematologist of client’s admission ​
• Morphine 1 mg by mouth every 4 hours as needed for pain greater than 5/10​

Pain is the most prominent feature when a client is admitted with a sickle cell crisis.Nurses must ensure that these clients receive adequate pain relief and nurses need to advocate for the client with the provider. The nurse should contact the provider to clarify the dose and frequency of the morphine as a client with a sickle cell crisis will need greater pain control. The recommendation is that these clients receive a continuous intravenous analgesic along with an analgesic scheduled on an as-needed basis for breakthrough pain. This client is only prescribed a small dose of an as-needed medication given orally which will not manage the client's pain when in a sickle cell crisis. The nurse should remain professional in communication with the provider and collaborate to ensure adequate pain control measures are in place. The other prescriptions are expected for a client in a sickle cell crisis.