PRACTICE EXAM SOLUTION F OR NCLEX RN: 5 COMPLETE DOCUMENT

PRACTICE EXAM SOLUTION F OR NCLEX RN: 5 COMPLETE DOCUMENT

The RN is dropping a urine specimen to the lab. Which RN action is necessary?

1.) Always put urine container in a biohazard ziplock bag 2.) Deliver by hand to lab w/in 1 hr of obtaining the specimen 3.) Deliver the urine specimen thru tubing system 4.) Label urine container w/ room # - CORRECT ANSWER 1 => ALL containers need to be in biohazard ziplock bags

Explanations:

• = not that important, do this w/ CSF; T = not necessary
• = true; highly discouraged
• = Do NOT do this; name, MR#, DOB, time of collection & sign

The RN is giving d/c instructions to a 10 yr-old boy w/ a fractural radius bone. Which observation requires the RN to refer pt to home health?

1.) The boy didn't go to playroom during hospital stay 2.) The father work prn shifts 3.) The boy's mother has bruises around her neck 4.) The mother is anxious to leave the unit - CORRECT ANSWER 3 => Violence in family is a risk factor for child abuse

-red flag: abuse in house?

Explanations:

• = maybe has other kids

This has resources available to promote health, prevent illness, & retain pt independence as safely as possible - CORRECT ANSWER Home Health Care

(Home Health Care) This person coordinates the care for pt btwn hospital & home setting - CORRECT ANSWER Case managers

(Home Health Care) The ______ should plan ways to adapt the home environment to pt's current functional ability - CORRECT ANSWER RN

(Home Health Care: Case managers, & RN) Optimal functioning may be enhanced by what 3 things? - CORRECT ANSWER 1.) Installing in bathroom => grab bars & raised toilet seats

2.) Obtain durable medical equipment => cane, walker, wheelchair

3.) DECREASE fall risk by:

=> using night lights => wearing well-fitting clothing & nonskid shoes => removing throw rugs => & securing electrical cords against base/backwards

An enema is given to a pt w/ impacted level the pt's HR drops from 80 to 50 bpm (bradycardia) once the RN starts introducing the enema. Which action does the RN take 1st?

1.) Withdrawal the rectal tube 2.) Reduce the flow rate of the enema 3.) Stop the enema 4.) Position pt on (L) side - CORRECT ANSWER 3 => stop right away -causes Vagal stimulation

Explanations:

• = do 3rd

• = do 4th; not approp. stop immediately
• = do 2nd; Yes, to remove the tube

A pt admitted after a MVA, pt has a BMI of 17. Which assessment will the RN identify as a health problem?

1.) Hydromorphone allergies 2.) Arthritis 3.) Pressure injury 4.) Low BP - CORRECT ANSWER 3 => underwt. pt would have a (-) impact normal healing

• prone to pressure injuries in bony prominances

*BMI low if <18.5 = underwt.

What is the normal body mass index? - CORRECT ANSWER 18.5/19 -25

If a pt has a BMI under 18.5/19 what does this mean? - CORRECT ANSWER Under weight

If a pt has a BMI >25 what does this mean? - CORRECT ANSWER Over weight

Barbinski (+) sign in a 12-month old when the does DO NOT fan apart from the big toe?

True or False - CORRECT ANSWER False

A COPD pt diagnosed w/ emphysema. The pt starts getting anxious & confused. What is the 1st action the RN should take?

1.) Raise the O2 flow rate from 2-4L/min 2.) Help the pt perform breathing exercise 3.) Check the pt's serum sodium

4.) Assess the pt's BP - CORRECT ANSWER 2 => Prevents collapse of alveoli & helps the pt control the depth & rate of breathing -helps keep alveloi open

Explanations:

• = very cations; a lot of O2 flushes out CO2 = resp, distress; <2L, prvent CO2 narcosis

• = Not relatable
• = not relatable

This is a state where pt's w/ hypercapnia develop depressed mental status - CORRECT ANSWER CO2 narcosis

Dealing w/ CO2 narcosis, what are the 2 things that a pt's w/ hypercapnia (increased CO2) develop depressed mental status include? - CORRECT ANSWER 1.) Confusion 2.) Somnolence & lethargy, which may progress to => coma & death

The RN is taking care of multiple pts/ Which pt will the RN assess 1st?

1.) Pt w/ CHF & reports retrosternal pain 2.) Pt who has laproscopic abd. surgery 2 hrs ago & is sleeping 3.) Pt who had a (L) lung lobectomy 15 hrs ago & is positioned on (R) side 4.) Pt who has am appendectomy 10 hrs ago w/ vesicular lung sounds on lower lobes - CORRECT ANSWER 1 => Pt w/ CHF reporting signs of MI. Pt w/ chest pain will be considered in MI until proven otherwise -> retrosternal pain = deadly serious

• result of MI/ on high alert

--pain behind sternum, intrascapular pain, crushing pain

Explanations: