OVER 150 MOSTLY TESTED EXAM QUESTIONS AND ANSW ERS

OVER 150 MOSTLY TESTED EXAM QUESTIONS AND ANSW ERS

SOLVED SOLUTION FOR NCLEX RN: 12

The night shift RN just got report, she is taking care of a new admission, a 5 yr-old girl w/ epiglottis. Which action is approp. for the RN to implement?

1.) Send the pt to radiology for a CXR w/ NAP 2.) Check for a gag-reflex using a tongue depressor 3.) Draw the orders for ABGs & report the results to the HCP 4.) Assess O2 sat & SpO2 & initiate IV antibiotics as ordered - CORRECT ANSWER 4 => Antibiotics should be started ASAP, epiglottis in school-aged children is Life-threatening.

Explanations:

• = Life threatening, do NOT send w/ an NAP; NOT safe
• = NEVER do this; compete obstruction occurs inflammation, edema, lost the pt
• = Do NOT need ABGs; pt will start crying & obstruct airways

A pt was admitted through the ED complaining of R-sided weakness & trouble speaking. The unit knows that the pt should be maintained in ....

1.) Sims recumbent position w/ HOB elevated 30-45 degrees 2.) R-side position, w/ HOB elevated 30 degrees 3.) L-sided position w/ bed flat 4.) Supine position, w/ HOB elevated 30 degrees - CORRECT ANSWER 4 => Maintain the head in supine position & help DECREASE pt's ICP *S&S of CVA

Explanations:

• = this is a semi-prone, flex legs to abd. to the side; increase intra-abd. pressure

• = help pt excrete from lung

• = don't want flat b/c increase ICP or drain secretions

This is a sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain, which is classified as either thrombotic or hemorrhagic - CORRECT ANSWER Cerebral Vascular Accident (CVA)

(CVA) This classification is a thrombus or clot in the brain - CORRECT ANSWER Thrombotic

(CVA) This classification is caused by a slow or fast hemorrhage in the brain tissue, often related to HTN - CORRECT ANSWER Hemorrhagic

(CVA) What are the 8 Risk factors for having a CVA? - CORRECT ANSWER 1.) Hypertension

2.) Previous transient ischemic attacks (TIAs)

3.) Cardiac disease => Artherosclerosis => Valve disease => Hx of dysrhythmias => Particularly A-fib or A-flutter

4.) Advanced age

5.) Diabetes

6.) Oral contraceptives & hormone replacement therapy

7.) Smoking

8.) Alcohol >2 drinks/day

(CVA: 8 Risk Factors) What are the Cardiac diseases linked to CVA?

1.) Artherosclerosis 2.) ___a.)_____ disease 3.) Hx of __b.)___ 4.) Particularly ____c.)____ - CORRECT ANSWER a.) Valve disease b.) Hx of dysrhythmias c.) A-Fib or A-Flutter

(CVA: 4 Diagnostics) What are the 4 diagnostics that can confirm when a pt had a CVA? - CORRECT ANSWER 1.) Brain CT scan

2.) MRI

3.) Doppler flow studies 4.) Ultrasound imaging

(CVA: 10 S&S) What are the S&S for CVA?

1.) __a.)___ dysfunction (depends on where clot is) => ___b.)__ OR ___c.)___

2.) Change in ___d.)___

3.) ___e.)___ paralysis => burning sensation felt in hands, arms, legs, or feet

4.) Aphasia (ability to ____f.)____) & ____g.)___ (ability to communicate thru writing)

5.) Memory loss

6.) ___h.)___ impairment

7.) ___i.)___ dysfunction

8.) ___j.)____ changes

9.) ___k.)____ functional abilities:

=> Mobility => Activities of daily living (ADLs) => Elimination => Communication

10.) __L.)____: difficulty eating - CORRECT ANSWER a.) Bladder dysfunction

b.) incontinence c.) Retention d.) LOC e.) Paresthesia f.) Communicate g.) Agraphia h.) Vision impairment i.) Bowel dysfunction j.) Behavioral changes k.) DECREASE functional abilities L.) Dysphagia

(CVA: Nursing care) What is the nursing care for a pt who had a CVA? (9 things) - CORRECT ANSWER 1.) Control HTN to help prevent future stroke

2.) Maintain proper body alignment while pt is in bed => splints or bed-rolls & pillows to maintain functional position