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NCLEX Strategy & Client Needs

Latest nclex materials Jan 8, 2026 ★★★★☆ (4.0/5)
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NCLEX notes/ uworld LAPTOP

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  • Students also studied Terms in this set (769) Science MedicineNursing Save

NCLEX 3

1,392 terms elizabeth_staley5 Preview NCLEX uworld 1,721 terms kc_hallPreview

NCLEX Fundamentals: Safety and In...

36 terms bennbrookePreview Uworld 16 terms had A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher.The nurse should take which actions to properly operate the fire extinguisher? Select all that apply.

1.Aim the nozzle at the base of the fire 2.Pull out the pin on the handle 3.Shake the canister prior to use 4.Squeeze the handle to spray 5.Sweep the spray from side to side A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment (eg, fire extinguisher) is involved. The mnemonic PASS is often used to help

people remember the steps used in operating a fire extinguisher:

P – Pull the pin on the handle to release the extinguisher's locking mechanismA – Aim the spray at the base of the fireS – Squeeze the handle to release the contents/extinguishing agentS – Sweep the spray from side to side until the fire is extinguished (Option 3) The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire.The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client?

1.27 g, 1/4 in 2.25, 1/2 in 3.25 g , 1/2

  • 15 , 1 and 1/2 in
  • When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation.The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 2). Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus.(Option 1) A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue.(Option 3) A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped).(Option 4) Needles longer than 5⁄8 in (1.6 cm) are used to administer intramuscular injections.

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)?

1.Carpal tunnel syndrome [3%] 2.Diabetes mellitus [45%] 3.Sciatica [8%] 4.Small cell lung cancer [42%] SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine).(Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery).(Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH.The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?

1.Administer the prescribed as-needed milk of magnesia [16%] 2.Ask dietary services to add more fruits and vegetables to the client's tray [5%] 3.Notify the health care provider (HCP) [4%] 4.Perform a focused abdominal assessment [73%] Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client. The nurse can administer the as-needed laxative once it has been determined to be safe. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus.(Option 1) The nurse's first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions).(Option 2) The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the HCP has prescribed a new diet.(Option 3) The nurse should further assess the client before contacting the HCP.A client is brought to the emergency department after sustaining third-degree burns over 50% of the body.Which solution is the best choice for fluid resuscitation in this client?

1.

0.45% normal saline 2.5�xtrose in 0.9% normal saline (D5NS) 3.5�xtrose in water (D5W) 4.Lactated Ringer's solution The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes.Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma (Option 4). LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock.(Option 1) Hypotonic solutions (eg, 0.45% normal saline) quickly leave the intravascular space and are not useful in replacing intravascular volume. They may also contribute to peripheral and interstitial edema, which can lead to pulmonary complications.(Option 2) Hypertonic solutions (eg, 5�xtrose in 0.9% normal saline [D5NS], 3% saline) can cause further electrolyte imbalances in a client with severe burns, resulting in hypernatremia, hyperchloremia, and arrhythmias.(Option 3) Although technically an isotonic solution, 5�xtrose in water (D5W) behaves as a hypotonic solution when dextrose is metabolized by the body and free water is released to the tissues rather than remaining in the intravascular space.

The nurse is caring for a 7-month-old client during a well- child visit. Which of the following gross motor skills should the nurse expect to identify at this age? Select all that apply.

1.Bears full weight on feet with support 2.Moves from lying down to a sitting position 3.Pulls up into a standing position from sitting 4.Sits using hands for extra support 5.Walks while holding on to furniture Childhood development usually occurs in an orderly and predictable manner, with more complex skills being acquired as age increases. Fine (eg, grasp) and gross (eg, posture, balance, movement) motor skills are assessed during routine well-child visits to identify normal development and detect delays.During infancy, gross motor development begins with head and neck control and progresses to skills such as turning over, bearing weight on the arms in a prone position, sitting with the head erect, standing, crawling (ie, abdomen touching floor), creeping (ie, abdomen lifted off floor), and walking. By age 7 months, infants should be able to bear their full weight while standing with caregiver support and sit with minimal support from their hands (ie, tripod sitting) (Options

  • and 4).
  • (Option 2) By age 7 months, infants can roll over, but the ability to move from a prone to a sitting position is not expected until age 10 months.(Option 3) Some infants learn to pull themselves up into a standing position early, but this is not expected until age 9-10 months.(Option 5) Walking while holding on to furniture is not expected until age 11 months.During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound?

    1.Low Fowler's position with knees bent [64%] 2.Prone to prevent further evisceration [2%] 3.Side-lying lateral position [3%] 4.Supine with head of the bed flat [29%] Wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. It is considered a medical emergency. The nurse should remain with the client while calling for help. The health care provider should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery.(Option 2) Prone positioning would put undue pressure on an open incision and protruding bowel and could contaminate the open wound.(Option 3) A side-lying lateral position (recovery position) is often used following emergency situations such as cardiac arrest or seizure, but it will not lessen the tension placed on this open wound.(Option 4) Supine with the head of the bed flat may actually increase tension placed on the open wound.

Occupational HIV postexposure prophylaxis: High-risk

contact (prophylaxis recommended) Exposure of Mucous membrane, nonintact skin, or percutaneous exposure Exposure to Blood, semen, vaginal secretions, or any

body fluid with visible blood (uncertain risk:

cerebrospinal fluid, pleural/pericardial fluid, synovial fluid, peritoneal fluid, amniotic fluid), Low-risk contact (prophylaxis not recommended) Exposure to Urine, feces, nasal secretions, saliva, sweat, tears (with no visible blood)

Timing: Initiate urgently, preferably in the first few hours

Continue for 28 days. Regimen

≥3-drug regimen recommended:

Two nucleotide/nucleoside reverse transcriptase inhibitors (eg, tenofovir, emtricitabine) Plus Integrase strand transfer inhibitor (eg, raltegravir), protease inhibitor, or non- nucleoside reverse transcriptase inhibitor

Cephalosporin HAIRYHyperglycemic Anaphylactic shock if allergic Insufficient platelet (thrombocytopenia) Renal problem if they are allergic Yellow poop (diarrhea) While the nurse and unlicensed assistive personnel are turning an intubated and heavily sedated client during a bath, the client coughs and expels the endotracheal tube. What is the priority nursing action?

1.Assess respiratory rate and breath sounds to ensure ventilation is occurring [26%] 2.Deliver rescue breathing with a bag-valve-mask attached to 100% oxygen [58%] 3.Immediately alert the health care provider and prepare for reintubation [10%] 4.Initiate a code blue to prepare for potential cardiac arrest due to hypoxemia [3%] Accidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2).(Option 1) Assessing the respiratory system is important but isAccidental extubation is a medical emergency. A sedated client is unable to protect the airway and requires immediate reintubation. If a client is accidentally extubated, the nurse should remain with the client, protect the airway using the head-tilt chin-lift or the jaw-thrust maneuver if spinal injury is suspected, and deliver breaths using a bag-valve-mask with 100% oxygen until reintubation is achieved (Option 2).(Option 1) Assessing the respiratory system is important but is not the priority action. Rescue breathing should not be delayed, as sedation significantly depresses respiration. Assessment is important for a new problem but not for an existing one, especially if delayed care can lead to life-threatening complications.(Option 3) Another nurse can notify the health care provider. Oxygenation is the priority action.(Option 4) While there is a risk for cardiac arrest, the nurse should support the client's airway and breathing to prevent arrest. A code blue should be initiated if cardiac arrest occurs. Rescue breathing should not be delayed, as sedation significantly depresses respiration.A nurse is caring for a client with unstable angina. After 5 minutes on a nitroglycerin IV infusion, the client reports relief of chest pain but a new dull, throbbing headache.What is the appropriate nursing action?

1.Decrease the infusion rate and reassess the client's report of pain [23%] 2.Document the finding and administer prescribed acetaminophen [57%] 3.Notify the health care provider and request a CT scan of the head [3%] 4.Stop the infusion immediately and notify the health care provider [15%] Nitroglycerin is an antianginal medication that causes potent vasodilation (coronary and systemic) and is used in the treatment of acute coronary syndrome (eg, unstable angina, myocardial infarction). IV nitroglycerin administration requires continuous cardiac monitoring and frequent blood pressure assessment (eg, every 15 minutes for the first hour). Headache is an expected side effect from vasodilation of cranial vessels and should decrease with continuing nitroglycerin therapy. As long as the client does not have severe hypotension (eg, systemic blood pressure <90>

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Added: Jan 8, 2026
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NCLEX Strategy & Client Needs 8 studiers in 3 days 5.0 (4 reviews) Students also studied Terms in this set Science MedicineNursing Save NCLEX 3 1,392 terms elizabeth_staley5 Preview NCLEX uworld 1,721...

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