NCLEX RN practice test NGN

NCLEX RN practice test NGN Leave the first rating Students also studied Terms in this set (23) Science MedicineNursing Save NGN/NCLEX Prep Questions/Ration...24 terms racheladenham134 Preview PEARSON NCLEX-RN Questions & R...199 terms Candice_Haygood Preview NCLEX-RN Practice Set 60 terms nancypdllPreview NCLEX 10 terms Cdu the nurse reviews the record of a client diagnosed with acute kidney injury (AKI). It is most important for the nurseto review which lab value?

URINE SPECIFIC GRAVITY

*** specific gravity can indicate fluid volume excess or deficit and is the most important of the lab values to assess a client is admitted for dehydration. the nurse observed that the client appears restless and reports difficulty breathing. The nurse auscultes the client's lungs and hears bilateral basilar crackles. Which action does the nurse take first?ELEVATE THE HEAD OF THE BED AND STOP THE iv INFUSION *** it addresses the clients difficulty breathing and indications of fluid volume overload A client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration biospy.The client says "I am frightened I have never had this test before and I dont know what to expect." Which statement will the nurse include when responding to the client's concerns? SATA ***

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

-There is a risk of bleeding so will monitor the test site frequently BM biopsy- can be done in pt room or treatment room -pressure dressing applied to reduce rf bleeding -stinging and discomfort furing biopsy is expected -monitor for bleeding -local anesthetic used a client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which action does the nurse include in the client's plan of care? SATA

• rotate the gastrostomy tube 360 degrees once daily
• check for a slight in-and-out movement of the gastrostomy tube

**** 4-8 hrs of enteral feeding should be added to the bag to reduce contamination. the tube should be rotated 560 daily to reduce skin irritation.

The nurse provides medication intruction to a client who is precribed 60 mcg/hour dose of transdermal fentanyl every 3 days. which client statement indicates understanding of the instructions?"I SHOULD AVOID PLACING A HEATING PAD OVER THE MEDICATION PATCH" *** heat source will increse the absorption of med through the skin.the nurse assess clients for potential spousal abuse. The nurse is most concerned if a client makes which statement?"ITS MY FAULT BECAUSE I PUSH MY SPOUSE'S BUTTONS" *** individuals who expereince spousal abuse often accept blame, become compliant, and feel helpless a client diagnosed with rheumatoid arthritis is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which laboratory value does the nruse report the health care provider?

WHITE CELL COUNT 14,000/MM3

***indicative active infection Acute kidney injurycan be due to hemorrhage and hypotension, which cause poor kidney perfusion.The nurse meets with the parent of a yound adolescent male client in the pediatric clinc. The parent voices concern that the child has developed some breast enlargement and tenderness. which response by the nurse is correct?

THIS IS A TEMPORARY DEVELOPMENT THAT OCCURS IN MANY MALES AT THIS

AGE *** breast enlargement and tenderness (gynecomastia) occurs in up to 70% of males in early adolescents due to instability of changing hormone levels.Gynecomastia at puberty usually resolves as boys age and their hormone levels become more stable the nurse provides care a client diagnosed with diastolic heart failure. The nurse observes the recent onset of the above rhythm. which action by the nurse is priority?

ASSESS LEVEL OF CONSCIOUSNESS AND ORIENTATION

*** LOC and orientation are the best indicators regarding the effect of atrial fibrillation on cardiac output. A change in LOC and or alertness is the earliest indication of poor cardiac output.A client diagnosed with end-stage kidney disease is prescirbed hemodialysis treatements three times a week.After two weeks of treatment, the client states, "I have a headache when the dialysis finished. Is this normal?" which response by the nurse is best?"HEADACHES MAY OCCUR AT THE BEGINNING OF TREATMENT AND SHOULD IMPROVE OVER TIME" *** Headache, nausea, and fatigue may occur after hemodialysis due to disequilibrium syndrome. This is caused by the rapid removal of electrolytes and solutes from blood contributes. A reduction of blood flow during dialysis decreases the risk of disequilibrium syndrome.The nurse administers metoclopramide IV to a client 30 minutes before cisplatin is scheduled to be given. the client asks the nruse why metoclopramide is being given.Which response will the nurse provide the client?"METOCLOPRAMIDE CAN PREVENT OR REDUCE ADVERSE EFFECTS ASSOCIATED WITH CISPLASTIN" ***Metoclopramide can prevent or reduce the indicence of nausea and vomiting with cisplastin and an adverse effec of metoclopramide is diarrhea. It increases gastric and intestinal motility and increases stomach emptying The nurse prepares to suction a client's tracheostomy.Which nursing action is the priority for the client?

AUSCULTATE THE CLIENTS LUNGS

*** assessment should occur prior to implementation. The client's cardiopulmonary status must be monitored before, during, and after suctioning

• amount of suction should be set to 80-120 mmHG

the nurse provides care for a client immediately after arrival in the ED. Emergency personnel report that the client was involved in a head-on collision with immediate loss of consiousness. Which is the first action taken by the nurse?

EVALUATE OXYGEN SATURATION LEVELS

*** when prioritizing care for a client, the nurse uses the ABCs. O2 sat levels allow the nurse to monitor the pt's airway -GCS is too broad During a urinary bladder catheter insertion with a size 16 french catheter on an older adult male client, the nurse feels increased resistance. Which action by the nurse is best?

STOP THE INSERTION AND INSTRUCT THE CLIENT TO TAKE DEEP BREATHS

*** for the safety of the client, the nurse should never force a catheter if there is increased resistance. Instructing the client to take deep breaths will help to relax the urethral muscles and facilitate passage of the catheter.-catheter should not be withdrawn and reinstered, as this increases the rf infection the nurse reviews the medical record of a client who is confused. the client has soft wrist and ankle restraints in place. the nurse determines care is effective if which action is documented? SATA

• client placed in room near the nursing station
• clients spouse notified that restraints are in place for safety

****restraints should be discontinued if the patient becomes alert and oriented -restraints should be attached to the bed frame the nurse in the health care providers clinic assesses a client with a diagnosis of epilepsy who takes phenytoin.Which client assessment finding most concerns the nurse?

SLURRED SPEECH AND RASH

*** the presence of a rash is very concerning for a client taking phenytoin due to the possibility of steven-johnson syndrome, a rare but serious skin condition that would require hospitilization. In addition, slurred speech may indicate difficulty with speaking or swallowing -nystagmus is a common adverse effect of phenytoin that subsides with use The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stage of healing. The nurse accesses the client's medical record and notes the client was trated twice last month for reported back pain after two seperate falls.The client was treated two months ago for a perforated eardrum. Which action by the nurse is priority?

CONTACT SOCIAL SERVICES

***the adolescents hx suggest that there might be abuse. the law mandates that the nurse report know or suspected child abuse by collaborating with social services and law enforcement.complications of acute kidney injury-electrolyte imbalance, cardiac dysrhythmias, and fluid volume excess how to maintain serum creatinine within normal limits prepare client for hemodialysis the nurse provides care for a client who is prescribed assist control mechanical ventilation with PEEP of 5 cm H20. Which action will the nurse include in the client's plan of care? SATA -strict handwashing before suctioning

• administer pantoprazole 40 mg intravenous daily
• change client position every 2 hrs

*** pantoprazole a proton pump inhibitor(PPI) wil decrease the risk of aspiration of gastric contents.pneumoniapts with chronic lund conditions are more likely to develop pneumonia, due to pervious lund damage. The resp distress this pt is experiecning is an acute response to irritants which led to bronchial inflammation. With the history of asthma and recent exposure to animal dander and infectious children, the pt is at high risk to develop pneumonia.