Nclex

Question 1

Total knee arthroplasty (TKA) understanding or no understanding of the teaching provided.

Answer 1

understanding:

“I’ll call my surgeon if my incision gets red or has drainage.”
“I’m allowed to bear weight on my right leg.”
“I can probably drive in a few months

no understanding
“I can stop taking my blood thinner when I get home.”
“I’ll have physical therapy for about a week.”

Question 2

Massive bleeding from gastric or duodenal ulcers

Answer 2

presents as hematemesis

Question 3

minimal bleeding from these ulcers can present as

Answer 3

melena

Question 4

massive upper GI bleeding occurs, the client may experience

Answer 4

dizziness
hypotension
and tachycardia

Question 5

Massive bleeding from gastric or duodenal ulcers
The nurse would administer

Answer 5

oxygen
respiratory support as needed,
start two large-bore intravenous lines for isotonic fluids
and blood replacement,
monitor vital signs,
hematocrit,
and oxygenation saturation.

Question 6

Warfarin

Answer 6

Anticoagulant
Atrial fibrillation

Question 7

Ibuprofen

Answer 7

Nonsteroidal anti-inflammatory drug
Chronic back pain

Question 8

Famotidine

Answer 8

H2 antagonist
Gastric acid reflux

Question 9

Trimethoprim / sulfamethoxazole

Answer 9

Anti-infective agent
Urinary tract infection

Question 10

Verapamil

Answer 10

Calcium channel blocker
Angina pectoris

Question 11

Assessing a client for complications of a deep vein thrombosis,

Answer 11

The nurse recognizes
shortness
signs of pulmonary embolism,
hematuria
ecchymosis
signs of hemorrhage, which can occur as a result of heparin therapy.

Question 12

Urinary catheter obstruction

Answer 12

Assess the three-way urinary catheter for kinks and blood clots.

Question 13

Bladder spasm

Answer 13

Keep the three-way urinary catheter attached to the client’s thigh and encourage the client to relax his bladder muscles.

Question 14

Postoperative TURP (transurethral resection of the prostate)

Immobility

Answer 14

Help the client to get out of bed, ambulate, and sit in a chair as soon as permitted after surgery.

Question 15

Urine blood clots (Postoperative TURP)

Answer 15

Maintain the rate of continuous bladder irrigation to keep the urine clear.

Question 16

Pain

Answer 16

Assess for pain every 2 hours and administer pain medication as needed.

Question 17

atorvastatin

Answer 17

HMG-CoA reductase inhibitor
Management of hyperlipidemia

Question 18

carvedilol

Answer 18

Beta-adrenergic blocker
Management of hypertension and heart failure

Question 19

digoxin

Answer 19

Cardiac glycoside
Increase myocardial contractile force

Question 20

lisinopril

Answer 20

Angiotensin-converting enzyme inhibitor
Management of heart failure

Question 21

diagnosis of sickle cell disease, the nurse is aware

Answer 21

Acute vaso-occlusive episodes
Stroke,
Acute kidney injury,
and Sepsis.

Question 22

Hydroxyurea ( sickle cell disease (SCD)

Answer 22

Be sure to follow up on all lab testing because the drug can lower your red blood cell and platelet count.”

“Because the drug can cause birth defects, be sure to use contraception to prevent pregnancy.”

“Try to avoid people with infection and public places where there are large crowds.”

“Hydroxyurea has been known to cause several types of cancer, so be sure to follow up with your medical appointments.”

Question 23

Acute pulmonary edema

Answer 23

Administer furosemide 20 mg intravenous push.

Question 24

Exacerbation of heart failure.

discharge instructions will the nurse provide

Answer 24

A “Weigh yourself each day at the same time on the same scale to monitor for fluid retention.”
B “Contact your primary health care provider if you experience cold symptoms lasting more than 3 days.”
D “Notify your primary health care provider if you experience shortness of breath or chest pain while resting.”
E “Do not use table salt, avoid salty foods, and read labels on all food items to ensure your diet is low in sodium.”

Question 25

Secondary to severe weakness in his lower extremities.recent echocardiogram indicates moderate heart failure with an ejection fraction (EF) of 38%. Prescribed aspirin and a variety of cardiac medications. The nurse’s initial client assessment findings are listed

Answer 25

Blurred vision
Sinus rhythm with preventricular contractions
Bilateral basilar crackles
Creatinina kinase 1200 U/L
Potassium 5.2mg

Question 26

The client is diagnosed with rhabdomyolysis. Prescriptions to place a large-bore intravenous catheter and administer normal saline 0.9% at 125 mL/hr are received.
Information missing

Answer 26

Client who has left ventricular dysfunction, the nurse assesses for COMFUSION.
CHEST PAIN related to inadequate myocardium perfusion.
OLIGURIArelated to inadequate renal perfusion.
Manifestations of pulmonary congestion include dyspnea, crackles, and tachypnea.
Place the client in a sitting position and administer supplemental oxygen and furosemide intravenous push.

Question 27

Sickle cell disease is preparing for discharge to home with her parents.
nurse is planning health teaching to help the client prevent a sickle cell crisis

Answer 27

“Avoid overly strenuous physical activities.”
“Avoid temperatures that are extremely hot or cold.”
“Engage in low-impact, low-energy exercise three or four times a week.”
“Eat a healthy diet that is rich in fruits and vegetables.”
“Avoid high altitudes, such as mountainous areas.”
“Avoid smoking and tobacco use, including vaping.”
“Dress appropriately for the temperature that you are in.”

Question 28

Echocardiogram results indicate moderate heart failure with an ejection fraction (EF) of 38%. The client’s wife provides a list of his current medications.

Answer 28

Aspirin
325 mg orally once a day Salicylate Prevention of platelet aggregation.

Atorvastatin
20 mg orally once a day HMG CoA reductase inhibitor Management of hyperlipidemia.

Carvedilol
12.5 mg orally twice a day / Beta-adrenergic blocker / Management of hypertension and heart failure.

Digoxin
0.125 mg orally once a day Cardiac glycoside Increase myocardial contractile force

Lisinopril
2.5 mg orally once a day
Angiotensin-converting enzyme inhibitor
Management of heart failure

Question 29

18-year-old African-American female client reports shortness of breath, chest discomfort, fatigue, and fever for the past 3 days. She is admitted to the medical-surgical nursing unit with pneumonia and probable sickle cell disease

nursing actions are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the client’s care at this time.

Answer 29

States she has had no shortness of breath since hospital discharge: INDICATE

Has 21 pitting edema in both ankles and feet : NO ESENCIAL.

Blood pressure = 134/76 mm Hg : INDICATE

Has had no chest pain since hospital discharge.
Contraindicated

Reports feeling like she has more energy now when compared with before her hospital stay.
Contraindicated

Has new-onset fungal skin infection: INDICATE

Question 30

Nursing action is appropriate for each potential heart failure complication.

Answer 30

Acute pulmonary edema
Administer furosemide 20 mg intravenous push.

Fatigue
Consult a cardiac rehabilitation specialist.

Hypokalemia
Administer potassium supplements.

Cardiac dysrhythmias
Monitor electrocardiogram, oxygen saturation, and serum electrolyte levels.

Hypoxemia
Administer oxygen therapy.

Question 31

sickle cell disease (SCD) Additional assessment finding that require follow-up by the nurse.

Answer 31

Report shortness of breath, chest discomfort, fatigue, and fever for the last 3 days

Both parent are SCD carriers. but the client has had no symptoms of the disease.

Reports feeling “lightheaded” at time.

Hemoglobin 11.4

Hematocritos 36%

Red blood cell 3.2

WBC 15000

Oral temp 101.6

Blood pressure 98/48

Question 32

Exacerbation of heart failure chronic renal insufficiency, and coronary artery disease including a myocardial infarction and coronary artery bypass surgery 22 years ago.

For each assessment finding, indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).

Answer 32

States she has had no shortness of breath since hospital discharge: EFFECTIVE

Has 21 pitting edema in both ankles and feet
Blood pressure = 134/76 mm Hg: INEFFECTIVE

Has had no chest pain since hospital discharge:
EFFECTIVE

Reports feeling like she has more energy now when compared with before her hospital stay: EFFECTIVE

Has new-onset fungal skin infection: Unrelated

Question 33

The primary health care provider prescribes hydroxyurea to prevent or reduce sickling or painful events caused by SCD. Which health teaching by the nurse about hydroxyurea is important to include?

Answer 33

“Be sure to follow up on all lab testing because the drug can lower your red blood cell and platelet count.”
“Because the drug can cause birth defects, be sure to use contraception to prevent pregnancy.”
“Try to avoid people with infection and public places where there are large crowds.”
“Hydroxyurea has been known to cause several types of cancer, so be sure to follow up with your medical appointments.”

Question 34

Result of the client’s diagnosis of sickle cell disease, the nurse is aware that she could have multiple complications including acute severe pain periods known as

Answer 34

Severe pain periods known as Acute vaso-occlusive episodes.

monitors for other major SCD complications such as Stroke, Acute kidney injury, and Sepsis.

Question 35

Diagnosed with a right lower extremity deep vein thrombosis (DVT) after surgery. Five days later the heparin infusion is discontinued and the nurse prepares to discharge the client on warfarin.
teaching will the nurse include as part of discharge planning

Answer 35

“Elevate your legs on a couple of pillows when in bed.”
“Wear knee-high graduated compression stockings.”
“Apply prolonged pressure over cuts and nosebleeds.”
“Increase your activity slowly and rest when needed.”
“Keep your scheduled appointment at the Coumadin (Warfarin) clinic.”
“Contact your primary health care provider if your stool is black and tarry.”
“Monitor your heart rate and blood pressure daily.

Question 36

Diagnosed with a small bowel obstruction, received general anesthesia yesterday during an exploratory laparotomy, experienced a difficult recovery after surgery, and has been on bedrest since admission. Venous duplex ultrasonography of her lower extremities and laboratory studies are completed. Results from these diagnostic tests include the following data:

Answer 36

Apply sequential compression devices to bilateral lower extremities. CONTRAINDICATE

Teach the client to avoid foods high in vitamin K. Non-Essential

Plan to check the client’s platelet count in the morning. INDICATE

Use ice packs and massage techniques to decrease leg swelling and pain. CONTRAINDICATE

Assess for hematuria and blood in the client’s stool. INDICATE

Place client’s legs in a dependent position when sitting in a chair. CONTRAINDICATE

Monitor the client’s intake and urinary output. INDICATE