Readiness Assessment Bootcamp

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NCLEX REVIEW

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX-RN Practice Questions For 2...Teacher 33 terms TutorDkPreview NCLEX 113 terms lala The nurse is caring for a client who is 30 weeks pregnant with preeclampsia. It would be priority for the nurse to monitor the client for?Clonus

Rationale: Clonus is a rhythmic, involuntary muscle contraction indicating

worsening disease and impending seizures --> this can cause progression to eclampsia Preeclampsia causes CNS irritability and hyperreflexia The nurse is teaching a client who is newly prescribed allopurinol for gout. Which of the following information should the nurse include?You should increase your fluid intake to 3 liters of non-caffeinated beverages

Rationale: Gout occurs when the body is unable to catabolize dietary purine,

causing uric acid to deposit in joints, particularly the hands and feet, resulting in inflammation, swelling and pain.When taking allopurinol the client should increase their fluid intake up to 3 L per day and to take it with meals to minimize nausea and vomiting, avoid alcohol, if rash develops d/c immediately The nurse is assessing a 3-year-old client with Kawasaki disease (KD).Which of the following findings should receive highest priority?Restlessness and pallor

Rationale: Kawasaki disease causes widespread inflammation and acute vasculitis

that can lead to an MI.In young children, pallor, restlessness, vomiting and tachypnea are signs of an MI When caring for victims of intimate partner violence Assist the client in safety planning and provide information and resources to help the client make their own decisions

ostomy skin careAn ostomy skin barrier opening should be less than or equal to 1/8 inch away from the stoma's edge to prevent skin breakdown The charge nurse is supervising a staff nurse who is preparing to administer an infusion of chemotherapy to a client with stage 4 cancer.Which of the following actions by the staff nurse would require follow-up by the charge nurse?Instructs the client to limit fluid intake after the infusion to help prevent vomiting

Rationale: Clients receiving chemotherapy are at risk for dehydration due to

potential vomiting; client should increase fluid intake to 2-3 L/day during chemo The emergency department nurse is caring for a client who just arrived by ambulance following a car accident and is reporting a swollen, sore right shoulder.Which of the following non-pharmacological pain interventions should the nurse implement?Ask the client if he would like to watch the football game Rationale: distraction is an effective non-pharmacological treatment for reducing acute pain The charge nurse is observing a staff nurse administering an eye irrigation.Which of the following actions by the staff nurse would require the charge nurse to intervene?Directs irritant laterally among conjunctival sac from outer to inner canthus

Rationale: irrigation fluid should flow from inner to outer canthus

The nurse is preparing to administer metoclopramide for a client.Which of the following findings would be a contraindication to administer the medication?Client has absent bowel sounds in all 4 quadrants

Rationale: Metoclopramide is a prokinetic and antiemetic medication that works

by increasing peristalsis and gastric motility to treat gastroesophageal reflux disease (GERD), diabetic gastroparesis (delayed gastric emptying), or nausea and vomiting.Because metoclopramide stimulates gastric motility and gastric emptying, it is contraindicated if a bowel obstruction is suspected because increasing peristalsis against an obstruction could cause bowel perforation, sepsis, and death.The nurse is caring for a 6-year-old client who has a history of sickle cell disease and bacterial pneumonia.The nurse notes the client has 10/10 pain, pallor, dry mucous membranes, and is coughing.Which of the following actions should the nurse take first?Administer IV bolus of lactated ringer's

Rationale: The nurse should first administer fluids and electrolytes to reverse

sickling and increase tissue perfusion to improve oxygenation SCD complications include ACS or vaso-occlusion of the lungs.ACS is managed with IV fluids and electrolytes, blood transfusions, antibiotics, pain management, and incentive spirometry.The nurse is planning care for a client who had a craniotomy.Which of the following interventions should the nurse include in the client’s plan of care? Select all that apply.Maintain the head of bed in fowler position Rationale: To prevent ICP after a craniotomy: Maintain head of bed ≥30° with neck in neutral position.Reduce environmental stimuli.Administer analgesia and sedation.Administer stool softeners to prevent straining.

The nurse has taught a pregnant client who has been craving ice chips and eating them throughout the day.Which of the following statements by the client would indicate a correct understanding of the teaching?I need to have my hemoglobin level checked Rationale: pregnant clients almost always have iron-deficiency anemia. A classic sign of this is Pica, where the client craves non-food items such as clay or ice chips.The nurse is caring for a newly admitted 10-year-old client with type 1 diabetes who has diabetic ketoacidosis and has begun an IV 0.9% sodium chloride (normal saline) and IV insulin infusion.Which of the following actions should the nurse take?Collect serum potassium

Rationale: DKA treatment with IV insulin and fluids requires collecting regular

serum potassium levels to monitor hypokalemia and hourly blood glucose levels to titrate insulin Uterine ruptureTear in the uterine wall during labor presenting with prolonged fetal decelerations and weakening maternal contractions The nurse is planning care for a client with Stage 4 chronic kidney disease (CKD).It would be a priority for the nurse to monitor the client for Muscle weakness and nausea

Rationale: Hyperkalemia symptoms include muscle weakness, chest pain, and

nausea The nurse has administered theophylline to a client with chronic obstructive pulmonary disease (COPD).Which of the following findings would require immediate follow-up?Restlessness

Rationale: Theophylline is a bronchodilator used to manage asthma and COPD.

Theophylline toxicity causes central nervous system stimulation presenting as tremors, restlessness, insomnia, etc, diarrhea, etc.The pediatric nurse is caring for a 9-year-old client.Which of the following statements is most appropriate for the nurse to make to support the client’s cognitive development?If I tap this hammer on your knee, it sends a signal to your brain to make your leg kick.Rationale: Children in Piaget's concrete operational stage: Are 7-11 years old Understand cause and effect Can classify and sort items Understand the concept of conservation Develop logical thinking and understand concrete events The nurse is planning a staff education program about vaccinations.Which of the following information should the nurse include? Select all that apply.Live vaccines should not be given to pregnant clients, clients aged 65 years or older should receive the pneumonia vaccine, it is recommended that clients receive a tetanus vaccine every 10 years Rationale: Live vaccines are not commended in pregnant clients due to the risk of the fetus contracting the infection. Additionally, live vaccines are not recommended for immunocompromised clients.Tetanus vaccines are recommended every 10 years to ensure there is an adequate number of antibodies to prevent tetanus if exposure occurs The nurse is caring for a newborn client admitted with his mother to the hospital after a home delivery. The newborn has an axillary temperature of 96.9 F (36.1 C) and was placed under a radiant warmer.Which of the following actions should the nurse take next?Obtain a blood glucose level

Rationale: Newborns with hypothermia metabolize glucose for heat production.

This eventually causes hypoglycemia.

The nurse is preparing to administer IV furosemide to a client with acute decompensated heart failure.Which of the following would be a contraindication to administer the medication?Elevated serum creatinine level Rationale: Loop diuretics treat fluid overload by blocking reabsorption of sodium, chloride, and potassium.When administering diuretics, the nurse should hold the medication for hypotension, monitor for hypokalemia, and hold the loop diuretic for elevated creatinine because loop diuretics are nephrotoxic and can damage the kidneys.The nurse is assessing a newborn client who is 30 minutes old.Which of the following findings should receive the highest priority?Skin Pallor

Rationale: newborn pallor indicates inadequate perfusion to the skin. The nurse

should notify the healthcare provider, obtain a pulse ox, and complete a cbc.Murmurs are benign in the first 24 hrs after delivery; newborns breathe irregularly and can experience apnea periods lactic more than ore equal to 20 seconds.Newborn gruntingIndicates respiratory distress and occurs when the epiglottis closes to keep air within the alveoli.The nurse cares for a newly admitted client with rhabdomyolysis. The nurse notes that the client’s cardiac monitoring shows peaked T waves. The client reports a fluttering heartbeat and chest pain.Which of the following actions should the nurse take first?Administer iv calcium gluconate

Rationale: When severe hyperkalemia is present from rhabdo, calcium gluconate

should be administered first to stabilize cardiac cell membranes and prevent dysrthymias.Iv insulin with dextroseinsulin pulls potassium into the cell, lowering serum potassium levels, while dextrose prevents hypoglycemia caused by insulin administration.The charge nurse is assisting a new graduate nurse with post-mortem care for a client who died unexpectedly in the intensive care unit.Which of the following actions by the new graduate nurse would require the charge nurse to intervene?Shaves the client's face before the family viewing of the body

Rationale: Postmortem care includes asking family members about grooming and

viewing preferences, including family in care tasks if requested, and leaving all lines and tubes in place if autopsy is required Sudden pain relief in appendicitisIndicates potential appendix rupture The nurse is caring for a client with a deep vein thrombosis in the left calf.The nurse should prioritize monitoring the client’s Pulse oximetry reading

Rationale: When caring for a client with DVT, the nurse should prioritize

monitoring for hypoxemia The main concern for is venous return. Monitoring distal pulses would be more useful in clients with peripheral artery disease.The charge nurse is supervising a staff nurse who is teaching a client with Parkinson disease about newly prescribed controlled-release (CR) levodopa-carbidopa.Which of the following statements by the student nurse would require follow-up by the charge nurse?This medication will cause less nausea if you take it with a protein-rich meal

Rationale: Take carbidopa levodopa 30 minutes before or 1 hour after meals,

swallow the tablet whole, sit at the edge of the bed before standing due to orthostatic hypotension