Nclex Tips

Question 1

Rule of Nines

Answer 1

Head and Neck 9%
Each upper ext 9%
Each lower ext 18%
Front trunk 18%
Back trunk 18%
Genitalia 1%

Question 2

Birth weight doubles

Answer 2

by 6 months and triples by 1 year

Question 3

Cranial Nerves

Answer 3

O lfac           Some 
O ptic           Say
O cul            Marry
T roch          Money
T trig            But
A abd           My
F acial           Bro
A udit            Says
G glossoph   Big
V agus           Bras
A ccessory    Matter
H ypoglo       More

Question 4

Dumping Syndrome

Answer 4

Increase fat and protein, small freq meals

wait 1 hour after meals to drink

Question 5

Allen Test

Answer 5

Occlude Ulnar and Radial until hand blanches then release ulnar.
if hand pinks up then ulnar is good for ABGs

Question 6

Chest Tube

Answer 6

Collection chamber Far Right

Continuous bubble far left = suction chamber

Water chamber seal = bad if it is bubbling (air leak)
tiding is normal

If the tube detaches - Putin sterile water

Question 7

Hirchsprung’s

Answer 7

Bile obstruction
No bile is upper obstruction
Ribbon like Stool

Question 8

Cane walking

COAL

Answer 8

Cane
Opposite
Affected
Leg

Question 9

Late Decels

Answer 9

1. LLR position
2. O2 @ 8-10 LPM
3. Increase IV Fluid
4. Pit off
5. Call MD

Question 10

Bacterial meningitis

Answer 10

is inflammation of the meninges of the brain and spinal cord caused by infection.

infants and children age <2 include fever, restlessness, and a high-pitched cry.

hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow.

permanent hearing loss, learning disabilities, and brain damage.

Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.

Question 11

Insulins

Answer 11

RALG.I.DG
regular insulin (fast)
aspart (fast)
lispro (fast)
glulisine (fast)
NPH - Isophane (intermediate)
detemir (long)
glargine (long)

1. Insulins
2. Main hormone in the
   metabolism of glucose
3. All Type 1 diabetics,
   Type 2 uncontrolled by diet
   and oral anti-diabetics

Risk for hypoglycemia, hypokalemia
- Regular Insulin can be pushed
for hyperkalemia, follow-up with D5

Fast Acting - 30min
Intermediate - 2-4 hours
Long Acting - 6-8 hours

Question 12

Neologisms

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 12

made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: “I would like to have a phjinox.”

Question 13

Echolalia

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 13

repetition of words, usually uttered by someone else

Question 14

Tangentiality

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 14

going from one topic to the next without getting to the point of the original idea or topic

Question 15

Clang associations

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 15

rhyming words in a meaningless, illogical manner. Example: “The pike likes to hike and Mike fed the bike near the tyke.”

Question 16

Word salad

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 16

a mix of words and/or phrases having no meaning except to the client. Example: “Here what comes table, sky, apple.”

Question 17

Loose associations

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 17

rapid shifting from one idea to another, with little or no connection to logic or rationality

Question 18

Perseveration

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 18

repeating the same words or phrases in response to different questions

Question 19

Concrete thinking

impaired thought processes seen in individuals with schizophrenia include the following:

Answer 19

literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, “The grass is always greener on the other side,” would be interpreted to mean that the grass somewhere else is literally greener

Question 20

Sickle Cell Anemia

Vaso-occlusive crisis Lab results

Answer 20

elevated reticulocytes
elevated bilirubin
Anemia.

Question 21

Ulcerative colitis who has abdominal distension, bloody diarrhea, and fever

Answer 21

likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection and other forms of infectious colitis.

Question 22

Statin medications

…the client’s liver function tests should be assessed.

Answer 22

Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client’s liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy.

Question 23

Hepatic encephalopathy (HE)

Answer 23

is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood.

Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.

Question 24

Spider angiomas

Answer 24

(eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver.

Question 25

Jaundice

Answer 25

occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy.

Question 26

Amylase and lipase are enzymes

Answer 26

from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis.

Question 27

Acute urinary retention

Answer 27

is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3).

Question 28

pulsus paradoxus

Answer 28

To measure the pulsus paradoxus, place a blood pressure cuff on the patients arm and very very slowly deflate the cuff while listening for brachial pulsations. Note the pressure that you first hear with pulsations during expiration (which will be the highest).

Place client in semirecumbent position
Have client breathe normally
Determine the SBP using a manual BP cuff
Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure
Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure
Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox
The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

Question 29

A low-residue diet

Answer 29

, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes.