Nclex review: tough practice Questions 1 Archer review

Nclex review: tough practice Questions 1 Archer review

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Archer NCLEX Study Bank Question...152 terms Kimberly_Peacock47 Preview Archer NCLEX 78 terms HernandezOsuna89 Preview NCLEX 689 term erv The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.Gloves being worn to pass out meal trays Sterile water used to irrigate nasogastric tubes Single-use blood pressure cuffs for clients with contact precautions Sterile gloves used to provide perineal care during bed baths New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN) Gloves being worn to pass out meal trays Sterile water used to irrigate nasogastric tubes Sterile gloves used to provide perineal care during bed baths These observations indicate an ineffective use of resources. To promote cost- effective care, the nurse manager should correct these by instructing staff that gloves are not used while passing or retrieving a meal tray. Gloves would only be used during preparing the client's food, as required for dietary staff. Warm tap water is used to irrigate an NGT. The gut is not sterile; therefore, using sterile water would waste resources. Sterile gloves used to provide perineal care during bed baths are not used. During a bed bath, regular (clean) gloves are used and changed frequently during a bed bath.Your client is on complete bed rest for seven days. Which of the following is the priority nursing diagnosis for this client?

• Risk for sensory deprivation related to complete bed

rest

• Risk for thrombosis related to complete bed rest
• Risk for impaired tissue integrity related to complete

bed rest

• Risk for urinary stasis related to complete bed rest
• Risk for thrombosis related to complete bed rest

"Risk for thrombosis related to complete bed rest" is the priority nursing diagnosis for a client on complete bed rest for seven days, as immobile clients are at an increased risk for thrombus formation. One of the dangers of a deep vein thrombosis is the development of a pulmonary embolus. A pulmonary embolus occurs when a portion of the thrombus or clot breaks off, travels to the lungs, and subsequently obstructs the pulmonary artery, altering the blood supply to lung tissue. Pulmonary embolus has various presenting features, ranging from asymptomatic to shock or sudden cardiac arrest. Therefore, "risk for thrombosis related to complete bed rest" is the priority nursing diagnosis for this client based on Maslow's hierarchy of needs.

You are assigned to supervise a client care unit. Over the last several months, the nurses in the unit have told you that the unit dose dispensing of medications by the pharmacy has not been accurate at all times. Fortunately, there have been no medication errors as a result of these inaccuracies. Which of the following actions should be prioritized?

• Praise the staff for catching these inaccuracies
• Investigate and explore these near misses
• Investigate and explore these medical errors
• Report these inaccuracies to the State Department of

Health

• Investigate and explore these near misses

hoice B is correct. As the supervising nurse on your client care unit, you should investigate and explore the near misses similar to how you deal with sentinel events. Near misses, such as these inaccuracies, should be reported per hospital policy to be studied and examined to circumvent future errors.The nurse cares for a client in the emergency department with suspected substance intoxication A 31-year-old male client was brought to the emergency department (ED) by police after being found acting bizarrely at a local park. The client is hyper-alert and oriented. His speech is fast, and repeatedly states that 'someone is after him.' He has vomited twice approximately 100 mL of opaque fluid.Oral temperature 99.5 F (37.5° C) Pulse 110 bpm Respirations 22/minute BP 193/113 mm Hg Oxygen saturation 95% on room air.indicate if it is consistent with alcohol intoxication or amphetamine intoxication or both Paranoia Vomiting Hypertension Tachycardia

Alcohol: Vomit and tachycardia

Amphetamine: Paranoia, hypertension, vomiting, and Tachycardia

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? SATA Leafy greens Garlic Nuts Butter Turkey Garlic Nuts and Turkey Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI).

The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?

• Notify public health services
• Dim the lights in the assigned room
• Obtain blood cultures
• Explore the client's feelings regarding the diagnosis

choice C is correct. Bacterial meningitis is a medical emergency, and priority actions for the nurse are to assess the client's airway, breathing, and circulation; beyond the assessment of the ABCs and vital signs, the nurse should immediately establish a peripheral vascular access device and obtain blood cultures and laboratory work such as lactic acid and complete blood count. Lactic acid is a marker that may support the co-existing diagnosis of sepsis. The client will need an immediate lumbar puncture which will definitively exclude or confirm the diagnosis of bacterial meningitis. Considering this client has been diagnosed with bacterial meningitis, the nurse must collect blood cultures and then administer prescribed antibiotics that are aggressively dosed. Antibiotics commonly prescribed for bacterial meningitis include ceftriaxone and vancomycin.You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment.Which of the following would be helpful in preventing this disease?SATA Amoxicillin Ciprofloxacin Rifampin Meningococcal conjugate vaccine Vancomycin Ciprofloxacin Rifampin Meningococcal conjugate vaccine Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected individuals. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease.Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often receive this vaccination before attending school.The nurse in the mental health unit is assessing a client with moderate anxiety. The nurse would anticipate which signs and symptoms to support this finding. Select all that apply.SATA increased pulse the feeling of impending doom reports of headache narrowing of the perceptual field inability to problem-solve or learn hyperventilation Narrowing of perceptual field, headache, increased pulse Moderate anxiety is characterized by a client experiencing - Narrowing of the perceptual field The slightly scattered thought process The client can problem-solve and learn, although not at an optimal level Somatic symptoms such as headache, urinary urgency, and muscle tension Sympathetic symptoms such as an increased pulse, respiratory rate, palpitations, voice tremors, and shaking According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation?Right task Right circumstance Right person Right direction and communication all choices are correct All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job.The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure.Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete.

A registered nurse arrives for a shift in a pediatric emergency department (ED). There are four pediatric clients in the ED. Which client would the nurse assess first?

• A one-month-old infant that is crying with retractions

during inspiration

• A 5-year-old with pneumonia and a 95% pulse oxygen

saturation

• A 10-year-old with diarrhea and vomiting and a

potassium level of 3.6 mEq/L

• A 15-year-old diabetic with a blood glucose level of

190 mg/dL Choice A is correct. Retractions demonstrate increased respiratory effort, meaning the pediatric client is in respiratory distress. Since retractions are a medical emergency and this pediatric client is exhibiting inspiratory retractions, thus indicating respiratory distress, this client should be the first client the nurse assesses.The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply.

The student:

obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference.places the BP cuff over the client's clothing garment.requests the client remove their hearing aid before obtaining a tympanic temperature.assesses the client's respirations after obtaining the pulse rate.obtains blood pressure by placing the client's upper extremity below their heart.places the pulse oximeter probe on the client's finger that has edema.places the BP cuff over the client's clothing garment.obtains blood pressure by placing the client's upper extremity below their heart.places the pulse oximeter probe on the client's finger that has edema.These actions by the student are incorrect and require the nurse to intervene. The accuracy of blood pressure measurement may be skewed if the cuff is placed over clothes because it may impede blood pressure cuff fit and distort auscultatory sounds. The cuff should be snug over the client's skin. Further, BP results can be inaccurate if the client's extremity is not supported or at the level of their heart. If the arm is unsupported, it may cause a false-high reading. Further, if the arm is above the client's heart, it may cause a false-low reading. Pulse oximeter probes should be applied on an extremity that is non-edematous, has good peripheral blood flow, and is not obstructed by a blood pressure cuff (the cuff should be on the opposite side of the extremity where the pulse oximetry is being measured).A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority?

• Apply pressure to sites with sandbag
• Palpate pedal pulses
• Assess for signs of claudication
• Apply warm compress to incision sites

Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP?

• Obtain a tympanic temperature for a client who

received naproxen one hour ago

• Record and empty a closed suction drain for a client

recovering from a mastectomy

• Help a client to pick out low-sodium foods on their

lunch menu

• Transport a client receiving an infusion of dopamine to

the intensive care unit Choice A is correct. UAPs may obtain vital signs under most circumstances. A tympanic temperature assessment is appropriate after a client receives an antipyretic such as naproxen. This task is appropriate to delegate.