NCLEX REVIEW QUESTION S

NCLEX REVIEW QUESTION S

Hypertensive crisis nursing priority assessment?

LOC

Hypertensive crisis treatment?

- IV NITRATES

- ANTIHYPERTENSIVES

Hypertensive crisis treatment medications?

- NITROPRUSSIDE, LABETALOL, NICARDIPINE

Client with CAD; rhythm strip showing a second-degree AV block, type 1. What should the nurse do first?

- MEASURE VITAL SIGNS

AV block can be associated with what?

• MI
• MEDICATIONS (Beta blockers, Digoxin)

Acute aortic dissection; priority prior to surgery?

• ADMINISTER IV LABETALOL (to maintain BP within normal ranges)

Signs and symptoms of hypovolemia?

- TACHYCARDIA

- HYPOTENSION

Hypovolemic shock?

NARROWING PULSE PRESSURE

Signs of adequate rehydration?

- CAP REFILL LESS THAN 3 SECONDS

• URINE OUTPUT >30ML/HR

- NORMAL SPECIFIC GRAVITY (1.003-1.030)

What can occur 24-72 hours after extensive abdominal surgery?

THIRD SPACING OF FLUIDS

What age group should be able to first eat with a spoon?TODDLER (by 18 months)

Client with sepsis and AFR. The adverse effect of PPV?

HYPOTENSION

Neutrophil count

2200-7700

(< 500 indicates SEVERE NEUTROPENIA) Black box warning contraindicated in pregnancy ARBs and ACE INHIBITORS

Acute failure exacerbation; lab?

INCREASED BNP

Water intoxication (more susceptible in infants) results in what?

HYPONATREMIA

Tetralogy of Fallot 4 specific characteristics (OPRV)

• Overriding aorta
• Pulmonary stenosis
• Right ventricular hypertrophy
• Ventricular septal defect

Tetralogy of Fallot patient should be placed in what position?

KNEE-TO-CHEST POSITION

IV opiates safest for clients who will give birth when?

2-4 HOURS AFTER ADMINISTRATION

Butorphanol tartrate IV safely given when and to who?

• NULLIPARA 7 cm DILATED WITH CONTRACTIONS

Butorphanol crosses the placental barrier peaking when and for how long?PEAKING at 30-60 MINUTES DURATION is 2-4 HOURS

Opioid administration may do what?

SLOW LABOR PROGRESSION IN THE LATENT PHASE

Latent stage of labor?0-5 cm

Active stage of labor?6-10 cm

Borborygmi sound

LOUD, GURGLING = INCREASED PERISTALSIS

(Gastroenteritis, Diarrhea)

Bruit sound

SWISHING OR BUZZING SOUND

Bruit indicates what?

TURBULENT BLOOD FLOW

Narcissistic personality disorder helps to maintain what?

SELF-ESTEEM

How much should a child weigh by 30 months of age?

~4X GREATER THAN THE BIRTH WEIGHT

Toddlers weight

SLOWS DURING TOD DLER YEARS WITH AN AVERAGE YEARLY WEIGHT GAIN

OF 4-6LBS

Purpura

REDDISH, PURPLE BLOTCHES ON THE SKIN THAT DO NOT BLANCH WITH

PRESSURE D/T BLEEDING UNDER THE SKIN

Abnormal finding of a boggy liver edge below the rib cage

HEPATOMEGALY

Babinski sign can indicate what?

AN UPPER MOTOR NEURON LESION FROM DAMAGE TO THE CORTICOSPINAL

TRACT

A normal Babinski sign in an adult

TOES TO POINT DOWNWARD

Where do you check a pulse on a 3-month old who has stopped breathing?

-BRACHIAL ARTERY

Third degree AV block on an ECG presents as what?

REGULAR RATE AND RHYTHM WITH DISSOCIATED P WAVES AND QRS

COMPLEXES

RAIU test for hyperthyroidism, what instructions are given?

-ANTITHYROID MEDICATIONS SHOULD BE HELD 5 -7 DAYS BEFORE

PROCEDURE

-NPO 2-4 HOURS PRIOR TO PROCEDURE

-MAY RESUME EATING 1 -2 HOURS AFTER SWALLOWING IODINE

-PATIENT WILL BE AWAKE AND WILL HAVE NO PAIN

-DO NOT BREASTFEED IMMEDIATELY AFTER TEST

General anesthesia

MALIGNANT HYPERTHERMIA (RARE)

Soft restraints; what can be delegated to the UAP?

- ASSIST WITH USING BEDPAN

- PERFORM ROM EXERCISES

- TURN AND REPOSITION

Preschool children; preprocedural education

- ALLOWING PARENTS TO STAY WITH CHILDREN

- TELLING THEM THE PROCEDURE IS NOT PUNISHMENT

- ASK THE CHILD TO ASK ANY QUESTIONS THEY MAY HAVE

-UTILIZE TOYS TO COMMUNICATE ABOUT THE PROCEDURE

Suspected pyloric stenosis; expected lab value?

HEMATOCRIT 57%

(d/t dehydration manifested by hemoconcentration (elevated hematocrit and elevated blood urea nitrogen)

Hypertrophic pyloric stenosis results in what?

PROJECTILE VOMITING

Projectile vomiting leads to what?HYPOkalemic metabolic alkalosis Theophylline for advanced COPD

BRONCHODILATOR WITH A LOW THERAPEUTIC INDEX AND NARROW RANGE

(10-20)

Draw blood levels for Theophylline when?30 minutes AFTER dosing

What 2 drugs increase Theophylline serum levels? C&C

- CIPRO

- CIMETIDINE

Mechanical prosthetic valves require what?

LONG-TERM ANTICOAGULATION THERAPY

(do not take Vitamin K supplements and do not change diet)

Bacterial meningitis precautions?

DROPLET

ICP- potential risk for bacterial meningitis

- IRRITABLE, FEVER, HIGH-PITCHED CRY

- CHANGES IN PUPIL REACTION, SUNSET EYES, DILATED SCALP VEINS

- POOR FEEDING, VOMITING, BULGING FONTANELLES

What is an amnioinfusion used for?

LOW AMNIOTIC FLUID

• Oligohydramnios or ruptured membranes