RN NCLEX Sample test 1 NGN

RN NCLEX Sample test 1 NGN Leave the first rating Students also studied Terms in this set (26) Science MedicineNursing Save Sample Test 3 - Priorities 20 terms julia_springhetti9 Preview Missed Questions - Kaplan 28 terms graceeelisabeth13 Preview NCLEX Sample Test 1 50 terms olarewaju_Preview Kaplan 28 terms Bel R= a disaster alarm has been declared at the hospital and many clients are expected. The nurse provides care for clients on the maternal-child unit. Which client on this unit is considered for discharge within the next hour? SATA

• a multipara client who delivered over an intact perineium 12 hours ago (stable rn

and can have a home visit follow up)

• a 3 day old breast feeding client with a total serum bilirubin of 12 (photo therapy

is considered for a client with a total serum bilirubin between 13-15 @ 72 hours of age. the bilirubin levels peak between 3-5 days of age. pt can have bilirubin levels drawn at 5 days of age in the outpatient lab) -a 2 year old client delivered by a mother recieving intrapartum antibiotic therapy for GBS. (stable) *** patient recieving antibiotics after 24 hours need to stay because we dont know if it was effective

• epigastric pain indicates a pending eclampsia and os unstable.

R: The nurse recieves change- of-shift report. Which client

does the nurse see first?

A CLIENT 10 HOURS POSTOP AFTER A RIGHT MASTECTOMY AND REPORTING

WET SHEETS UNDER THE BACK

*** feelings of wet sheets may indicate HEMORRHAGE from the operative site and need to be investigated immediately. the client is unstable and need to be investigated for potential bleeding.

• I chose " a client diag with COPD with a PAO2 of 70" but this level of

oxygenation is considered "normal to good" for COPD patients.R: Akathisia is evidenced by...- extrapyramidal symptoms seen in facial grimaces, nervous- looking hand gestures, and restless legs both during night and day.

• akathisia can happen in the first couple of week after taking antipschotic med

R: the nurse provides care for a client receiving

chlordiazepoxide. It is most important for the nurse to reinforce which expected finding to the client?

DROWSINESS AND CONFUSION

*** chloridaizepoxide is an anti-anxiety and sedative/hypnotic mediation used to treat anxiety and alcohol withdrawal. This medication causes drowsiness and sedation. It is important for this client to use caution when driving or operating equipment.

R: the nurse prepares to administer subcutaneous insulin

to a client. The nurse scans the insulin barcode and the prompt seen on the computer screen is for another nurse to verify the insulin dosage. Which action does the nurse perform first?

PREPARE THE CORRECT DOSE OF INSULIN IN THE SYRINGE

*** the first action of the nurse is to prepare the medication as prescribed. So the second verification can be a check of all parts of the prescription. High- alert medications have safeguards in place in regard to limiting access and providing alerts to promo safety.

R: the nurse prepares to insert a peripheral IV catheter in

a client iagnosed with T1DM who reports extreme thirst, frequent urination, and fruity smelling breath. Which nursing action demonstrates appropriate peripheral line placement? SATA

• insert IV catheter in one of the dorsal metacarpal veins ( dorsal metacarpal vein

allows rapid fluid resusitation because these veins are large and easy to find)

• insert IV catherer below the antecubital fossa ( if using the brachial vein, the

nurse should insert below or above the antecubital fossa to prevent the IV catheter from being dislodged or kinked)

R: a client is admitted to a rehabilitation enter for

management of a cervical spine injury. The client reports a severe headache. Which action does the nurse take first?

PLACE THE CLIENT IN A SITTING POSITION

*** A pounding headache and profuse sweating are indications of autonomic dysreflexia when experienced by a client with a spinal cord injury above T-6. The nurse should place the client in a sitting position to decrease BP and reduce the rf of cerebral hemorrhage.

• priority is to DECREASE THE BP
• autonomic dysreflexia is often caused by a full bladder

R: While significant potential complications are

associated with immobility, it remains an appropriate treatment for some conditions. Which client requires a period of immobilization for optimal recovery? SATA

• a client with orthopedic trauma resulting from a motor vehicle crash (restricted

motion is required for bone healing)

• an older adult client with an acutely inflamed joint due to rheumatoid arthritis. (

an ACUTELY inflamed joint, as with rheumatoid arthritis, should be rested until the acute inflammation is resolved)

• a client experiencing acute low back pain with no neuromuscular deficits (limited

immobility may be needed, but it should last no longer than 48 hours) *** There is no inflammation associated with osteoarthritis with no contraindication for mobility

• neither active intubation nor continuous IV infusions are contraindications for an

early progressive mobilization protocol.

R: The nurse provides care for a client follorwing a scleral

buckling. Which nursing action is most important?

ASSESS FOR NAUSEA AND VOMITING

*** nausea and vomiting increase intraocular pressure and could causing damage to the repaired area

• eye should not irrigated
• there should be no drainage from the eye.
• protective eyewear prescribed to the client by the HCP
• avoid sneezing, coughing, and straining at stool.
• scleral buckling compresses the sclera to repair a detached retina. Precautions

should be taken to prevent moving the eyes rapidly.

R: The nurse provides care for clients in the outpatient

pediatric clinic. It is most important for the nurse to perform tuberculosis screening on which client?

A CLIENT WITH A LIVE-IN CAREGIVER WHO JUST EMIGRATED FROM LATIN

AMERICA

*** clients traveling to endemic areas or who have prolonged, close contact with indigenous persons from endemic regions should undergo immediate skin testing

• tb is endemis to asia, middle east, africa, and latin america, and caribbean

countries, not europe.

R: The nurse prepares a community education class on

car seat information for new parents. which information does the nurse teach the new parents? SATA

• infants needs a rear-facing seat until they meet the highest weight and height

requirments given by the manufacturer

• convertible car seats can be used both rear-facing and forward-facing

*** booster seats are recommended until children are over 4 feet 9 inches or between 8-12 years old

• children over 13 can ride in the front seat

R:The nurse administers a dose of morphine sulfate to an

adult client. The nurse expects to observe which finding?

THE CLIENT LOOKS PHYSICALLY RELAXED

***nonverbal cues are the best indication of pain relief, especially when coupled with a verbal statement about pain level

• i chose "pt states they are feeling better" but it is wrong because we need to

assess nonverbal cues and verbal cues but nonverbal cues are more important

R: The nurse provides care for several clients

experiencing pain in the acure care setting. Which client does the nurse assess first?

A CLIENT ADMITTED FOLLOWING A MOTOR VEHICLE ACCIDENT REPORTS

ABDOMINAL PAIN

***the client is in ACUTE PAIN from recent MVA.I chose " a client admitted for spinal surgery reports lower back pain that radiates to the foot" but this is CHRONIC

R: the nurse prepares teaching material for a client newly

diagnosed with T2DM. Which information does the nurse make a priority for this client?

EXPLAINING THE DISEASE PROCESS

*** teaching the client newly diagnosed with T2DM should begin with an explanation about the disease process. Once the client understands the health problem, teaching about medication, diet, exercise, and actions to prevent complications can occur

R: A young adult client is diagnosed with T1DM. 2 days

after admission, the client begins reporting severe nausea. Which action does the nurse take first?

PERFORMS A COMPREHENSIVE CLIENT ASSESSMENT

*** Nausea is not usually associated with DM. It is important to assess the client to determine the cause of the nausea before implementing any actions.

R: the nurse hosts a seminar for local residents 3 mo after

a major flood damaged most of the town. Which action by the nurse is most important?

ALLOW PARTICIPANTS TO OPENLY SHARE THOUGHTS AND FEELINGS

*** after a major disaster or a mass casualty incident, promoting psychosocial wellness by encouraging participants to share their feelings about the flood is a priority for the nurse. First step toward effective coping.R= the nurse listens to change of shift report for clients on a medical unit. Based on the physical assessment findings given in report, which client does the nurse assess first?

A CLIENT DIAGNOSED WITH EMPHYSEMA WHO HAS DIMINISHED BREATH

SOUNDS ON THE LEFT, UNEQUAL CHEST EXPANSION WITH A NEW ONSET OF

CONFUSION

*** Diminished breaths may be found in emphysema, however, unequal chest expansion and diminished breath sounds on one side compared to the other with a new onset of confusion (possible hypoxia) suggests PNEUMOTHROAX

R: a primipara client in labor was admitted to the labor

area 2 hrs ago. The cervix is now 5 cm dilated and 100% effaced, and the fetal head is at -1 station. The membranes rupture, the fluid is clear, and fetal heart rate is normal. Which action does the nurse take first?

ENCOURAGES THE CLIENT TO VOID EVERY 1-2 HOURS AND TAKES THE

TEMPERATURE EVERY HOUR

*** voiding facilitates descent of presenting part. Taking the temperature is necessary because of ruptured membranes.

R: a client returns from surgery after a total hip

arthroplasty. The hip has a large surgical dressing and a collapsible drainage device. Which finding 2 hours after surgery requires the nurse to call the HCP?

THE CLIENT REPORTS INCREASED PAIN AT THE SURGICAL SITE.

*** increased pain indicated a possible dislocation of the prosthesis. Other indication include shortening of the affected leg, leg externally rotated, and a soft popping sound heard when the affected leg is moved.Y: hyperkalemiaSymptoms: muscle weakness, abdominal cramping, diarrhea, and palpitations after sustaining a crush injury, paresthesias, muscle cramping

Actions to take:

• place the client on a cardiac monitor
• request order for BMP (verifies kidney function and electrolyte balance)

Parameters to measure:

-Presence of peaked T waves

• BUN and creatinine levels (determine kidney function)

Things that can cause hyperkalemia:

• stage 2 chronic kidney disease
• ACE inhibitors (lisinopril)

Y: For a client in active labor the nurse performs

intermittent checks of the fetal monitor. Which finding is of concern and requires nursing intervention? SATA

• FHR variability of < 5 bpm ( no HFR or minimal indicate fetal acidosis)
• gradual decrease in FHR starting after the beginning of maternal contraction (

late decel indicate fetal distress from uteroplacental insufficiency)

• abrupt decrease in FHR greater than 15 bpm, then an abrupt increase ( variable

decels indicate umbilical cord or head compression)