Readiness Exam Questions NCLEX-RN

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Nclex readiness 234 terms joseph_RoodPreview readine 12 terms Sam Early signs of ICPchange in LOC Restlessness Confusion Slow Speech Delay in response Pupillary changes Impaired ocular movement Weakness one extremity or one side HA (constant, increases intensity) Early signs of bowel obstructionHigh-pitched bowel sounds are indicative of an early bowel obstruction and worsens as it develops.total laryngectomySurgical removal of the entire larynx- cannot speak/whisper cause trachea is closed off and air can no longer move air through the nasopharynx so client will have a hard time smelling.Educate client about having smoke detectors installed at home.What can cause the development of right sided heart failure?High blood pressure in the lungs.Higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure will excess the systemic pressure, The result is back flow to the right side of the hear and resulting right sided heart failure.Hyperventilation will cause what kind of acid base imbalance?Respiratory alkalosis since you blowing out an excessive amount of acidic CO2, you are left with an alkalosis state.

What is the Guthrie's test?Positive test (bad sign) indicates decreased metabolism of phenylalanine (metabolic disorder), leading to phenylketonuria. The normal level in newborns is 0.5-1. Guthrie test detects levels greater than 4. Only fresh HEEL blood can be used for this test, The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. A lack of protein intake can interfere with the test.Most reliable after the baby ingest a source of protein. Usually performed no later than 6-7 days after birth.NPO if have pancreatitis because?Reduce pancreatic enzyme from eating away your pancreas cause there might be a blockage. Also called autodigestion. Keep NPO and empty so it allow some time for healing. Can be painful.Health history data that shows increased risk for

developing cancer:

Family history Alcohol consumption Tabaco use Human papillomavirus (warts in various parts of the body and most common STI- depends on the strain)

The best indicator of ACTUAL fluid deficit:WEIGHT! I&O

Admission and current. It's an ACTUAL objective data.

MAOIs (monoamine oxidase inhibitors): AVOID what kind

of food?

Tyramine:

Eating food high in tyramine whole on MAOI's is dangerously high level of tyramine in the body. This can lead serious rise in blood pressure.

Foods such as:

aged cheese. cured meats, smoked or process meats, liver, pickled , sauces, soybeans, dried or overripe fruits. alcohol beverages (yeast), and caffeine such as tea/coffee.phenytoin is for? and how long should you push it? For seizures

• minutes (should not exceed 50mg/min in peds but 100 mg can be safely delivers

over a period of 2 min) What medication is used for mothers going through preterm labor and is used to stimulate maturation in baby's lungs?Betamethasone What assessment should be notified to the HCP when beta-blockers are ordered?Heart rate lower than 60 bpm HR lower than 60 should not be given beta-blockers since it does lower it even more.What order should you administer an IVP through a non- tunneled central venous catheter?

• Cleanse access port
• Connect 10 mL normal saline to access port
• Gently aspirate for blood
• Flush saline using push-pause method
• Administer med
• Flush with normal saline, then with heparin

heparin is usually given to maintain catheter patency for a longer period of time to prevent thrombus formation.

What is prednisone?What S/S can the nurse expect after client has taken it for two months?Prednisone is a steroid.Side effect of prolong use is decreased wound healing, hypertension (due to fluid and sodium retention) and moon face (due to fat distribution from prolong steroid use).Facial and body hair will increase with prolong steroid use as well and weight gain.How long can you administer blood for?Blood be administered within the 4 hour time frame due to risk of hemolysis and bacterial invasion. If not completed, send back to the lab to be discarded. Must be given within 30 min after pickup.What is the best indication of a positive Mantoux tuberculin skin test?A central area of induration of 15 mm surrounded by erythema.What is serotonin syndrome?(Everything is increased) Serotonin in the body is good and it helps stabilizes our mood/ feelings and happiness. Serotonin syndrome is too much of the hormone.

Serotonin syndrome: increased heart rate, sweating, dilated pupils, tremors,

twitching, hyperthermia, agitation, confusion, disorientation, hallucinations Rare and life-threatening event If a patient was given REGULAR insulin at 8, what time is the patient at risk for hypoglycemia?11 Regular insulin peaks after 2-3 hours of administration.What is sucralfate and what should you do if it is given with another medication?sucralfate should be taken 30 minutes AFTER administering another med.Sucralfate coats the stomach lining and will be harder for the body to absorb meds after taking it.What is glaucoma?A condition characterized by increased intraocular pressure and progressive vision loss.What is given to a client with herpes varicella zoster? -vir drugs such as acyclovir What is priority for sickle cell crisis?Fluids!Think HOP Hydration Oxygen Pain management What is captopril and how can it affect people planning to get pregnant?-pril (Ace inhibitor) it should not be taken during pregnancy because serious harm to the unborn baby.What s/s would prompt the nurse to discontinue nitroglycerin?Cool and clammy skin. Decreased cardiac output meaning too much vasodilation.

What should the nurse educate the client on buccal medication administration?Placed between gums and cheeks. Cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass the digestive system.Stinging may occur depending on the med and if swallowed could be inactivated by gastric secretions.What meds should nurse administer to patient suspected with an acute MI?

MONA Morphine O2 Nitroglycerin Aspirin What is celecoxib? What education should be given? Given to relieve pain/tenderness/swelling/stiffness caused by arthritis.DO NOT take with NSAIDS such as Ibuprofen GI complaints and headache are most common SE Notify HCP of black stools Provides relief of pain and swelling so you can perform normal ADL What is clang association?meaningless rhyming of words Patient with major depression would get ECT done.Patient as "how many of these treatments do you think I will need?"

Your best response:

Everyone is responds to treatment differently, but may require 6-12 or even 20 treatments.Nurse can answer general questions.Psych patient says "everyone here hates me," nurses best

response:

I cant speak for other but I don't hate you.Here the nurse is speaking for herself. Do not argue with what patient are saying and is nontherapeutic.What does it mean when Asian look down at the floor while you are giving instructions?The classified behavior is ATTENTIVENESS and respect for the nurse.Asians can consider eye contact rude and offensive.Nurse providing information regarding suicide at a high school assembly... what should the nurse include?Do not keep secrets Express concerns for a person expressing thoughts about suicide Inform group of suicide intervention sources Do not leave a suicidal person alone Who has the highest rate of suicide?Elderly

In particular:

-White elderly males > 75 yrs old -Widowed, living alone -Asian elderly females (highest among females) Ask patient "have you had thoughts of harming yourself?What to do with patients with OCD? with frequent hand rituals Allow time for rituals Provide positive reinforcements Create a regular schedule for taking client to bathroom Patient does not need a flexible but a structured schedule.