NCLEX-RN Test 1 NGN 10

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NCLEX EXAM PREVIEW

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VATI RN

60 terms kay The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of 30/min. What is the nurse's next action?

• Initiate chest compressions

Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains <60>

• Client who had a bowel resection 1 day ago and client with asthma

exacerbation.When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had a recent bowel resection surgery.The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide?

• "I plan to attend my grandchild's graduation next month"

Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview,

the nurse should assess:

• Access to psychiatric medications
• Availability of help during a crisis (counselor, family)
• Future goals and plans
• Home and environment risks
• Overall affect and level of energy
• Possible access to weapons

Clients who articulate long-term personal goals and family milestones are less likely to attempt death by suicide

The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry

technician notifies the nurse at 8:30 AM that the client is

in ventricular trigeminy. What is the nurse's priority intervention?

• Administer potassium supplement

In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise.This client's morning laboratory results show hypokalemia (potassium <3>1.5 mg/dL [133 µmol/L], anuric, weight <99>

• Explain the client's resuscitation directive to the client's child

Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes should be followed, even if they conflict with the wishes of loved ones The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first?

• Client who underwent coronary artery stent placement via femoral approach 3

hours ago and is reporting severe back pain A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery.Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing?

• Peripheral arterial disease

Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries.Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing

Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information.

WRONG

• Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,

blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible intact or ruptured blister)

Stage 1: Intact skin with nonblanchable redness

Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry

Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon,

muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar A client with type 1 diabetes mellitus has prescriptions for NPH insulin and regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9 mmol/L), and the breakfast tray has arrived. What action should the nurse take? Click the exhibit button for additional information.

• Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular

insulin in the same syringe, drawing up the regular insulin first Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn into the syringe before intermediate-acting insulin to avoid cross-

contaminating multidose vials (mnemonic - RN: Regular before NPH).

To prepare the mixed dose:

Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the solution.Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles.Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the entire quantity.A client is receiving packed RBCs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best action?

• Wait 1 hour after blood transfusion finishes administering amphotericin B

Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This enables the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B.Findings that require further investigation in a client with penetrating stab wounds to the neck, chest, and/or

abdomen include:

Unilateral chest wall expansion (one side of the chest expands more than the other) and diminished breath sounds, which indicate the presence of air (eg, open pneumothorax) or fluid in the pleural space (eg, hemothorax, pleural effusion) Vital sign instability (eg, tachycardia, hypotension, tachypnea, hypoxemia) and signs of poor perfusion (eg, skin pallor), which are concerning for hemorrhage and respiratory compromise

For each finding below, click to specify if the finding is consistent with the disease process of hemothorax or tension pneumothorax. Each finding may support more than one disease process.Hemothorax: results from the accumulation of blood loss in the pleural cavity -->

loss of intravascular blood vlolume: tachycardia, hypotension, unilateral

diminished breath sounds Pneumothorax is characterized by air inside the pleural space, which disrupts the negative pressure that maintains lung expansion, causing the lung to collapse either partially or completely. Tension pneumothorax develops if air enters but cannot escape the pleural space --> this trapping compresses the heart and great vessels and displaces the midline structures (trachea) to the opposite side.

Tension pneumothorax: tachycardia, hypotension, subcutaneous

emphysema/crepitus on palpitation (air gets into the tissue under the skin), unilateral diminished breath sounds (also tracheal deviation, hyperresonance to percussion) Endoctracheal intubation would worsen the existing pneumothorax by delivering positive pressure ventilation, which would increase intrathoracic pressure ==> compress the heart and great vessels and lead to cardiac arrest.Which intervention does the nurse anticipate next? WRONG

• Chest tube insertion

A tension pneumothorax is life-threatening and requires immediate chest tube placement to decompress the pleural space, promote reexpansion of the compressed lung, relieve compression of the heart and great vessels, and restore hemodynamic stability. The chest tube should be connected to a water seal drainage system and suction, which promotes evacuation of air and reestablishment of negative pressure in the pleural cavity. The water seal acts as a one-way valve, allowing air to exit the pleural space but not enter it The nurse is assisting the client with repositioning in bed when the chest tube becomes dislodged from the client's chest. Which action should the nurse perform first?

• Cover the insertion site with the palm of a gloved hand

If a chest tube is accidentally dislodged from the client's chest, the priority is to cover the insertion site to prevent atmospheric air from entering the pleural space. Ideally, a dry, sterile gauze dressing is placed over the site and taped on three sides; this allows intrapleural air to escape and prevents development of a tension pneumothorax. However, if the nurse does not have immediate access to sterile gauze, the priority is to place the palm of a clean, gloved hand firmly over the site until a dressing can be obtained