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NCLEX: Mix > Practice Test 2023: NCLEX-PN > Flashcards

Practice Test 2023: NCLEX-PN Flashcards

1
Q

Gunshot victim transported to ED via EMS. Needs emergency surgery no next of kin present.

What is the proper way to obtain informed consent

A

No informed consent is needed when life saving procedures are necessary to save a life

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2
Q

Which of the following describes Assessment

Data collection and validation
Direct care
Goal setting
Evaluation

A

Data collection and validation

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3
Q

Diagnosis is the 2nd step of the nursing process.

Which describes diagnosis

Planning and implementation
Evaluation
Data collection and validation
Goal setting

A

Planning and implementation

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4
Q

Which of the following is not part of the Self-actualization part of Maslows Hierarchy of needs

Spiritual growth
POV of others
Reaching Max Potential
Acceptance

A

Acceptance

Acceptance is part of the Self-esteem

Empowering Environment is also part of Self-actualization

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5
Q

Nurse is friends with a patient
After discharge the nurse hasn’t heard from the patient.
Nurse post on patient’s social media

Hey girl, haven’t heard from you since you left the hospital

What has the Nurse done

Broken the law
Written unethical statement
Dismissive of patients feelings
Nothing wrong

A

Broken the law

HIPPA

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6
Q

Which would you as an RN not assign to a new LPN

Assisting a post op patient 12 hours out of surgery with going to the rest room

Feeding a patient with early Alzheimer’s

Teaching a family about ambulating for the first time

Foley care

A

Teaching family about ambulation for the first time

RN should be first nurse to assess and teach a patient about ambulation after surgery

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7
Q

Nurse suspects patient is having a seizure in L&D unit. What is the most important intervention

Place patient of left side
Call code blue
Give patient magnesium
Check poc glucose on the patient

A

Place on left side to prevent aspiration

Call RAPID RESPONSE rather than code blue

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8
Q

Allopurinol 200mg

What is it prescribed for?

Precautions

A

Antigout Agent: Lowers uric acid
(Uric acid forms when Purines breakdown found in foods: Small canned fishes, beer, dried beans)

Drink 8 glasses of water daily

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9
Q

After Salem Sump NG tube

Client vomits moderate amount.
What is the most appropriate action to take?

A

Irrigate with 20mL NS

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10
Q

Priority action for a client who is a daily alcohol abuser.

  1. Reorient client to the environment frequently
  2. Maintain in a cool, darkened room
  3. Assist the client drinks more isotonic fluids
  4. Administer thiamine 100mg IM
A
  1. Reorient client to the environment frequently

Safety

Client may hallucinate and reoriention will maintain Safety

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11
Q

isoniazid (Antibiotic)
part of the cocktail for TB

Thus serious side effect

A

Liver injury

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12
Q

What is uneven skin pigmentation in the elderly associated with.

A

Normal finding

Skin becomes more avascular
Prone to pallor.
Long-term sun exposure produces white or gray Macules
Lentigines (commonly referred to as “liver spots”

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13
Q

Which of the following demonstrates understanding

Client prescribed clopidogrel 75mg

  1. I will have my blood tested regularly
  2. I will need to stop taking garlic tablets that I take for my cholesterol
  3. I can continue taking my Ibuprofen
  4. I will make sure to take a multi vitamin from now on
A
  1. I will need to stop taking garlic tablets that I take for my cholesterol

Garlic also inhibits platelets

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14
Q

Which finding at a fasting blood glucose Indicates gestational diabetes

40
100
140
180

A

180

140 is the maxium normal number

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15
Q

Phenytoin antiseizure medication

Major side effects

Speech: Slurred / Rapid
Energy: Hyper / lethargic
Coma / seizures

A

Slurred speech
Lethargy
Seizures
Spinning sensation
Nystagmus (Rapid eye movements)

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16
Q

Sertraline (Zolfot) SSRI

How long does it take to work

Common SE

A

4 weeks

SE

Nausea
Inability to sleep
Dry mouth
Decreased libido

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17
Q

Maslows hierarchy of needs

Bottom first / Most fundamental

A

Physiological
Safety / Security
Love and Belonging
Self-esteem
Self-Actualization

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18
Q

Applying Maslows Hierarchy

  1. Recognize Physical or Psychosocial
  2. Eliminate Psychosocial (Pain is Psychosocial)
  3. Does this make sense to the disease process
  4. Apply ABCs

Arrive at correct answer

A

Yeppers

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19
Q

Applying Maslows

Ruptured ectopic pregnancy/ laparotomy is scheduled

Most important for Plan of Care

  1. Fluid replacement
  2. Therapeutic communication
  3. Emotional support
  4. Oxygen therapy
A
  1. Fluid replacement

Eliminate 2&3 (Psychosocial)

Eliminate 4. Oxygen doesn’t make sense in the question. There is no mention of low oxygen levels nor is it to be expected

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20
Q

Applying Maslows

Anorexic girl 82 lbs & 5’ 4”
Labs: Hypokalemia, anemia, dehydration

Which has the highest priority

  1. Body image disturbance related to weight loss
  2. Self-esteem disturbance related to weight loss
  3. Impaired nutrition: Less than the body requirement
  4. Deficient cardiac output related to the potential for Dysrhthmias
A
  1. Deficient cardiac output related to the potential for Dysrhthmias

Eliminate 1 & 2 Psychosocial

Between 3 & 4 which one involves the ABCs, Keep number 4

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21
Q

On NCLEX you should assume you have an order for all “Dependent” nursing actions.

Ie. Giving a pill, orders, oxygen

T or F

A

T

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22
Q

Does “Assessment” always come before “Intervention”

A

Yes

Unless the question is looking for an intervention, due to the assessment already being done

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23
Q

6 hr post op ab surgery

Nursing Processs ADPIE

Most important action

  1. Have client use pillows to splint incision
  2. Instruct client how to safely get out of bed
  3. Reinforce dry dressing to provide more padding
  4. Turn client to check for bleeding underneath client.
A
  1. Turn client to check for bleeding underneath client.

Assess first, then intervention

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24
Q

ADPIE / ABC

child fell riding bike and has a possible fractured right Femur. Severe pain, conscious and alert

Which is the first action taken.

  1. Immobilize limb with splint and ask client not to move
  2. Collect data of the circumstances of the fall
  3. Place in semi-fowlers posistion to facilitate breathing.
  4. Check pedal pulse / blanching both legs and compare findings
A
  1. Immobilize limb with splint and ask client not to move

The question states “possible fracture”. Hence, the assessment was already done.

Eliminate 2 & 4 Assessments

Eliminate 3. There is nothing in the question that states breathing problems.

Just because ABC are one of the answers doesn’t mean you have to chose it.

Does the ABC make sense? In this case No

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25
Q

ADPIE

A child biking to school fell of bike. The child tells the nurse: I think I broke my leg.

What is the first action taken

  1. Immobilize affected leg with splint and instruct client not to move.
  2. Collect data of the circumstances surrounding the fall
  3. Place in semi-fowlers posistion to facilitate breathing
  4. Check appearance of leg
A
  1. Check appearance of leg

Determine if Assessment or Interventions is needed

Assessment comes first always

Eliminate 1 & 3 Interventions

Priority: Examination of leg is more urgent than the background story

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26
Q

Safety Strategy - Flow sheet

All possible answers are Interventions

Try to answer based on knowledge, if unable

What will cause the client the least amount of harm

Correct Answer

A

Imagine being an RN at MVH

Overnight and chilling

40$ ph, pension, vacation, sick days

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27
Q

Safety

Pediatric tonsillectomy/ unresponsive to antibiotics. After surgery child brought to clinical unit.

What action should be included in the plan of care?

  1. Institute measures to minimize crying
  2. Perform postural drainage q2h
  3. Cough & deep breathing hourly
  4. Provide ice-cream as tolerated
A
  1. Institute measures to minimize crying

Safety

  1. All answers are interventions
  2. Try to answer using your Knowledge
  3. What will cause my client the least amount of harm

(2.) Postural drainage can cause bleeding
(3.) Can cause bleeding
(4.) May cause child to clear throat and cause bleeding

The nurse must prevent postop hemorrhage.
1. Crying may irritate throat and increase chance of bleeding

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28
Q

Safety

Nurse doubts accuracy on MAR.
What action should they take first?

  1. Compare MAR with order in medical record
  2. Contact prescribing HCP
  3. Consult pharmacy
  4. Compare information about meds in a nursing book.
A
  1. Compare MAR with order in medical record

The nurse needs to know what the original order said.

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29
Q

Safety

Wrist restraints to dementia client
Which action is most appropriate

  1. Attach ties of restraints to bed frame
  2. Perform daily ROM to restrained extremities
  3. Remove restraints when in a wheelchair
  4. Explain restraints need to family only
A
  1. Attach restraints to bed psot.

ROM exercises need to be more frequent than daily. q4h

Only remove when supervised

Explain need to the client too

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30
Q

Priority

Bipolar stopped taking Lithium
No food or sleep for 2 days.
Upon admission what nursing action has the highest priority

1 reinforcement of importance for taking Lithium
2. Provide with safe environment with few distractions
3. Arranging food and rest for client
4. Setting limits on behavior

A

Food and Rest

Maslows hierarchy

Eliminate Psychosocial 1 & 4

Ask self if others make sense
Both make sense

Food and rest and physiological
Safety is 2nd to physiological

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31
Q

Safety

NG tube at low intermittent suction for client with intestinal obstruction.
2 hrs after insertion client vomits. While irrigating NG tube resistance is felt

Which action should be taken first

  1. Replace NG tube with larger one
  2. Turn client onto left side
  3. Implement continuous NG tube suction
  4. Continue NG tube irrigation
A
  1. Turn client to left side (Tip of tube maybe against stomach wall)

Steps:

1.All answers are Interventions = safety
2.Can you answer based on your knowledge
3. What will cause client least amount of harm?

  1. Replacement with larger NG tube can damage mucosa
  2. Continuous suction will erode mucosa
  3. NEVER FORCE IRRIGATION
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32
Q

To answer Priority questions properly

Use these 3 strategies

A

Maslows, nursing process, safety (abcs - if it makes sense)

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33
Q

Assisting client with ambulation when they begin to fall.

Most appropriate action

  1. Grasp client underarms and bend at the waist and assist client to the floor
  2. Place feet close together, place arms under clients Axillary, slide client to the floor
  3. Place arms around waist of client and assist to nearest chair or bed.
  4. Place feet wide apart, push Pelvis forward, and slide the client down one leg.
A
  1. Place feet wide apart, push Pelvis forward, and slide the client down one leg.
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34
Q

Clients radial pulse dropped from 72 to 56 bpm since last VS check 4 hrs ago.

Most important action for nurse

  1. Check oxygen sat levels
  2. Begin Ox at 2/L minute via NC
  3. Obtain BP
  4. Palpate bilateral pedal pulse strength
A

Obtain BP (Drop in HR = Drop in cardiac output = No blood to organs)

  1. Ox Sat levels NOT dependent on cardiac output, affected by Altered Respiratory Function
  2. More Assessment is needed before intervention
  3. Bilateral pulse strength is important But not as important as Overall BP
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35
Q

Client states “I feel short of breath” has NS infusion of 75mL/hour through PICC line

First action taken

  1. Obtain BP & apical HR
  2. Reassure client that SOB will improve
  3. Observe PICC insertion site
  4. Elevate HOB to 90°
A
  1. Elevate HOB to 90°

Intervention is needed because it’s ABC.

Shortness of breath requires immediate action

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36
Q

Vaginal delivery result3d in a still born

Most important action by the nurse

  1. Be available to the client to listen to expressions of grief
  2. Provide client with appropriate fluid replacement.
  3. Check client’s perineal pad frequently for excessive bleeding
  4. Tell client about measures to cope with severe uterine pain
A
  1. Check client’s perineal pad frequently for excessive bleeding

Maslows / ABC

Eliminate Psychosocial

No evidence of dehydration.
Evidence of blood loss due to giving birth (ABC)

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37
Q

Left or Right sided HF

Dyspnea, Orthopnea, frothy sputum, crackles, Pallor, fatigue, coolness, weak pulse, pulmonary edema.

Juglar vein distention, hepatomegaly, ascites, decreased bowel sounds, generalized edema

A

Left sided: Left Ventricle, unable to pump unoxygenated blood to body and Backs Up in the Lungs

Right sided HF
Right Ventricle unable to properly pump blood and results in BACKFLOW to Right Atrium & Venous Congestion

Dyspnea, Orthopnea, frothy sputum, crackles, Pallor, fatigue, coolness, weak pulse, pulmonary edema, Increased Creatinine & decreased urinary output due to poor renal perfusion

Juglar vein distention, hepatomegaly, ascites, decreased bowel sounds, generalized edema

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38
Q

2 most common causes of CKD
Chronic kidney disease

A

Hypertension & DM

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39
Q

Explain S&S of Hyperkalemia & Hypokalemia

A

As K goes so does the body except for Cardiac & Urine output

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40
Q

Which medication is used to treat Hyperkalemia

  1. Spironolactone
  2. Prednisone
  3. Naproxen
  4. Sodium polystyrene
A
  1. Sodium polystyrene (Replaces the K for Na in the GI tracts)

Spironolactone is a K sparing diuretic
Corticosteroids (Prednisone) lead to K retention
NSAIDS like Naproxen Increase K by Decreasing kidney ability to excrete K

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41
Q

Hyperkalemia

Which nursing actions are indicated

  1. Cardiac Monitor
  2. IV reg insulin & Dextrose 5%
  3. Maintain strict bed rest
  4. Anti seizure precautions
  5. Loop diuretics
  6. Monitor I& O
A
  1. Cardiac Monitor
  2. IV reg insulin & Dextrose 5%
  3. Loop diuretics
  4. Monitor I& O

Not indicated

Hyperkalemia doesn’t cause Seizures

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42
Q

Provide care to stable clients

Provide care to unstable clients

RN / LPN

A

Stable LPN

Unstable RN

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43
Q

Initiate oxygen treatments
Collect data and lab specimens
Monitor Is & Os
Blood Glucose
Apply dressings
Initial assessment
Give teachings and discharge
Insert & care for catheter & ng tube
Pass medication
Empty JP drains

Which are duties of LPN

A

Collect data and lab specimens
Monitor Is & Os
Blood Glucose
Apply dressings
Insert & care for catheter & ng tube
Pass medication
Empty JP drains

LPN may also

Maintenance of Oxygen delivery
Reinforce teachings

RN

Initial assessment

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44
Q

What roles does an LPN have in blood Transfusions / IVs

A

Monitor IV site / Blood Transfusion after first 15 minutes

Hang or change bag IV fluid to existing line

Admin IV piggyback meds

Discontinue peripheral IV

Preform site care

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45
Q

An RN my assign a LPN to assess a client to help with making nursing judgments.

T or F

A

F

Assessment, Evaluation, & nursing judgments may not be assigned to LPNs

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46
Q

Most appropriate for an LPN

  1. Obtain VS for a newly admitted client with several fractures
  2. Monitor client client who had an Ovarian tumor removed 2 days ago
  3. Teach recently diagnosed DM client how to perform insulin injection
  4. Bathe and change clothes of client recovering for appendectomy
A
  1. Monitor client client who had an Ovarian tumor removed 2 days ago
  2. Obtain VS for a newly admitted client with several fractures (RN -Unstable)
  3. Teach recently diagnosed DM client how to perform insulin injection (RN- new teaching)
  4. Bathe and change clothes of client recovering for appendectomy (UAP)
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47
Q

Best assignment for LPN

  1. Help client recovering from surgery with bathing, linen change, and ambulation to bathroom
  2. Perform Head-to-toe assessment for client admitted yesterday with pneumonia
  3. Assess newly admitted client with high fever and productive cough
  4. Change dressings for a statis ulcer in a client with DM.
A
  1. Change dressings for a statis ulcer in a client with DM.
  2. Help client recovering from surgery with bathing, linen change, and ambulation to bathroom (UAP)
  3. Perform Head-to-toe assessment for client admitted yesterday with pneumonia (RN)
  4. Assess newly admitted client with high fever and productive cough (RN)
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48
Q

Client care should be assigned to LPN

  1. Assess new admit with severe ab pain
  2. Review education on birthing methods provided to a pregant client
  3. Provide bedside care for infant client with fever and discomfort
  4. Change dressings of a client who underwent partial mastectomy
A
  1. Change dressings of a client who underwent partial mastectomy

RN responsibility other actives

  1. Review education on birthing methods provided to a pregant client

A LPN may reinforce teaching but not evaluate them

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49
Q

Can a LPN educate about preprocedure instructions

A

Yes ?

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50
Q

LPN is floating to several units in the hospital. Which client-care activity is best for LPN

  1. Assist postsurgical client with ambulation to bathroom
  2. Checking with family members about effectiveness of discharge teachings.
  3. Instruct newly admitted client about diagnostic test preparation
  4. Changing the Purulent dressing of a client with stage 4 pressure injury
A
  1. Instruct newly admitted client about diagnostic test preparation

LPNs are trained to provide client education and physical preparation for diagnostic test.

  1. LPNs can change dressings but stage 4 is considered unstable
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51
Q

Can LPNs administer IV push medications

A

No

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52
Q

Can UAP fill out incident reports

A

Yes, if they witness the incident

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53
Q

When to use Hot / Cold therapy

A

Hot = chronic pain / muscle pain (Will bring more blood to the area Vasodilation)

Cold = Acute pain. (Will Vasoconstrict and lessen blood to area)

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54
Q

Strategy for Posistioning

  1. Are you trying to prevent or promote?
  2. What are you trying to prevent or promote?
  3. Think A&P

Correct answer

A

Become a NP by 47

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55
Q

Immediately after percutaneous liver biopsy, client should be placed in which posistion?

  1. Supine
  2. Right side-laying
  3. Left side-laying
  4. Semi-fowlers
A
  1. Right side-laying

Why?

After surgery what is the biggest risk?
Hemorrhage

To prevent Hemorrhage do we Apply or Not Apply pressure?
Apply Pressure

Where is the liver located?

Right side

Correct answer will Apply pressure to the right side-where the liver is located

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56
Q

Client gets angiogram for decreased circulation in right leg. After the angiogram what posistion should the client be put it?

  1. Semi-fowlers with right leg bent at the knee
  2. Side-laying with a pillow between the legs
  3. Supine with right leg extended
  4. High fowler with right leg elevated
A
  1. Supine with right leg extended

Think about it

Promotion or Prevention? Promotion of blood to right leg

What promotes blood flow to right leg?
Keeping right leg at or Below heart level

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57
Q

How to turn a client after a laminectomy?

  1. HOB 30°, client locks knees when turning
  2. Pillow placed between legs, body turned as a unit.
  3. Client straightens back and grasps side rails on opposite side of the bed
  4. HOB flat, client bends knees and rolls to the side.
A
  1. Pillow placed between legs, and body rolled as a unit.

Why?

Prevention or Promotion:
Promotion of a straight back

(After Lamenectomy client must not bend or twist torso)

Log Rolling = name of maneuver

58
Q

Client continues to report pain after appendectomy despite analgesics.
Which measure is most appropriate

  1. Notify HCP
  2. Place in semi-fowlers posistion
  3. Massage abdomen
  4. Guided meditation
A
  1. Place in semi-fowlers posistion

Notifying HCP is almost never correct

59
Q

Describe

Dorsal recumbent posistion

A

Supine with knees flexed; more comfortable

60
Q

Describe Use of Side Lateral posistion

A

Allows drainage of oral secretion

61
Q

Describe use of Sims posistion

A

Allows drainage of oral secretions and Rectal Exams

62
Q

HOB elevated Various Fowlers

Describe (2) general uses

A

Increases venous return

Allows maxium Lung Expansion

63
Q

Feet & legs elevated has this affect

A

Increases blood return to the heart

64
Q

Feet elevated and head lowered (Trendelenburg)

2 uses

A

Insert Central Venous Pressure Line CVP

Umbilical Cord compression

65
Q

Feet elevated 20°
Knees straight
Trunk Flat
Head slightly elevated
(Modified Trendelenburg)

2 uses

A

Increase Venous Return

Prevent Shock

66
Q

Elevation or Deelevation of extremity

Increases Venous Return & decreases blood volume to extremity

67
Q

Lithotomy posistion is
Flat on back, thighs flexed, legs abducted

Used for…

A

Increases vaginal opening for exam

68
Q

Prone posistion is Contradicted for people with this problem

A

Respiratory or Cardiovascular

69
Q

Knee to chest posistion is used for..

A

Maximal visualization of rectal area

70
Q

Client 6 months ago had a T6 spinal cord injury. Client reports Throbbing headache, face-chest-neck all red and diaphoretic

What is the first action

  1. Loosen clients upper body clothing
  2. Check fir fecal impaction
  3. Remove indwelling catheter
  4. Sit client in an upright posistion
A
  1. Sit client in an upright posistion

Client has Autonomic Dysreflexia (complication of >T6 spinal cord injury) EMERGENCY

All answers are correct but the First thing to do is sit up to reduce blood pressure

71
Q

Client diagnosed with right-sided stroke 2 weeks ago. When assisting with meals what is the most important

  1. Encourage swallow 4x
  2. Assist client to use straw to drink fluids with meal
  3. Instruct client to sit in chair 30 minutes after meal
  4. Provide 8oz milk with every meal
A
  1. Instruct client to sit in chair 30 minutes after meal

This question is asking about ASPIRATION PREVENTION.

Sitting for 30 minutes will help ensure food travles to the stomach

swallowing 4x is not needed
Straws and thin liquids are ASPIRATION risks
Milk makes excessive saliva, ASPIRATION risk

72
Q

Which requires intervention 48 hrs after right total hip arthroplasty

  1. Client is positioned high fowler during meal time
  2. Right & left legs are slightly abducted when client is supine
  3. HOB is 50° during morning oral care
  4. UAP places pillow between clients legs before turning the client
A
  1. Client is positioned high fowler during meal time

What is a big risk 48 hrs after total hip replacement? Subluxation (partial dislocation of hip)

  1. Elevation HOB >60 increases risk of dislocation
  2. Slight abduction decreases risk of dislocation
  3. HOB <60° Is not risk for dislocation
  4. Pillow between legs maintains slight abduction- correct
73
Q

What is the correct way for a client to pull them selves up from a sitting position using their walker?

A

None. Don’t use a walker to pull yourself up

Use arms of the chair, grab bars, or a counter.

A WALKER WILL TIP OVER

74
Q

Proper technique to go up stairs with a walker?

Down stairs?

A

Don’t use a walker on stairs

Have someone carry walker up stairs and use the hand rails

75
Q

Osteoarthritis is a condition that involves loss of…

A

Cartilage in synovial joints

76
Q

PAD is narrowing of upper and lower arteries caused by….

Clinical findings include

A

Atherosclerosis (build-up of fats, cholesterol, on artery walls )

Claudication (ischemic muscle pain that occurs with exercise)

77
Q

Hyperlipidemia is a major risk factor for…

A

CAD

Coronary artery disease

78
Q

Lordosis causes….

A

an unusually large, inward arch on the lower back, just above the buttocks. The condition may cause lower back pain.

79
Q

Psych Unit
Client asks “ Am I in a special radioactive shelter? When was it last checked for radioactivity?”
Which response is most appropriate?

  1. This is a hospital, and we don’t have a nuclear medicine dept here.
  2. Don’t worry your safe. There’s no radioactivity here
  3. I’m sure your safety is of concern to you, but this is a hospital
  4. Please share with me what makes you think there is radioactivity here.
A
  1. I’m sure your safety is of concern to you, but this is a hospital

In psych patients. Look for answers that reflect feelings and gives information

80
Q

Under most circumstances which treatment from the clients care plan will be provided first to a hospice patient

  1. Administer acetaminophen 650 mg rectal suppository
  2. Administer 0.5 mL oral liquid morphine 20mg/ mL
  3. Provide mouth care with oral sponge and water
  4. Change diapers and perineal care
A
  1. Administer 0.5 mL oral liquid morphine 20mg/ mL

Managing pain is normally the priority in hospice

81
Q

Describe skin when patient is near death

A

Molted- different color patches

82
Q

Which 2 findings indicate the client has expired

  1. No movement or breathing
  2. Unresponsive
  3. Cool Mottled skin
  4. Absence of apical pulse
  5. Absence of audible BP
  6. Dilated pupils
A
  1. No movement or breathing
  2. Absence of apical pulse

Not

Cool Mottled Grey skin can be present in the hours leading up to death

NonAudible BP maybe present several hours B4 death

83
Q

Most important question for a patient with OCD?

  1. Do you find yourself forgetting simple things
  2. Do you find it difficult to focus on a given task?
  3. Do you have trouble controlling upsetting thoughts
  4. Do you experience panic in a closed in area?
A
  1. Do you have trouble controlling upsetting thoughts. (OCD has trouble controlling intrusive, repeating thoughts)
  2. Do you find yourself forgetting simple things (Cognitive Disorder)
  3. Do you find it difficult to focus on a given task? (Depression)
  4. Do you experience panic in a closed in area? (Panic disorder)
84
Q

Seizure client states I hear drums
What does the nurse do first?

  1. Tell them to ignore it
  2. Place in a darkroom away from nurses station
  3. Ask followup questions
  4. Insert oral airway
A
  1. Insert oral airway- Prevents biting tongue during seizure

Before a seizure or migraine clients experience: Auras arepartial orfocal seizuresthat sometimes happen before a more severe seize occurs (characterized by brief sensory alterations)

85
Q

Which type of lung sound need follow up

Vesicular or Adventitious

A

Adventitious

86
Q

Pale, Cool, Sweaty skin
Slurred speech
Liable
HR 124

Thirsty
Urine often
Hungry
Dry mouth
Blurred vision

Hypoglycemia/ Hyperglycemia

A

Pale, Cool, Sweaty skin
Slurred speech
Liable
HR 124

Hypoglycemia

Thirsty
Urine often
Hungry
Dry mouth
Blurred vision

Hyperglycemia

87
Q

Why do patients get Tachycardia & Diaphoresis with Hypoglycemia?

Why do they have confusion, difficulty speaking, and stupor?

A

Tachycardia & Diaphoresis due to release of Epinephrine

Confusion, difficulty speaking, and stupor- Lack of glucose to brain

88
Q

Hypoglycemia <70 may cause this complication

  1. Osmotic diuresis
  2. Hypokalemia
  3. Hypovolemia
  4. Seizures
A
  1. Seizures

Lack of glucose in the brain leads to significant impairment

89
Q

Blood Glucose <60 Alert & Verbal

1st thing
2nd thing
Possibel 3rd thing

A

Give 15 G fast acting carb
Wait 15 minutes & Chexk BS
If <70 give 15 g fast acting carb

90
Q

Client receiving Paroxetine

Most important information to tell HCP

  1. Appetite change
  2. Recently started in Digoxin
  3. Applys sunscreen when going outside
  4. Drives car to work
A
  1. Recently started in Digoxin

Paroxetine (SSRI) can decrease ability of Digoxin to work (slow your heart rate downand improve the filling of your ventricles. Improves A fib )

  1. Weight loss is to be monitored with SSRI
  2. Sunscreen is needed Prevent photosensitivity SSRI SE
  3. Driving is allowed after determining response to Paroxetine
91
Q

DRN order. Which is the 1st action taken

  1. Administer life saving medicine
  2. Assess client for signs of death
  3. Open airway and give 2 breaths
  4. Summon emergency code team
A
  1. Assess for signs of death

No life saving measures given Including medication

92
Q

LPN is working in newborn nursery

Which assignment should they question

  1. 2 day old laying quietly alert with HR 185 BPM
  2. 1 Day old crying with bulging fontanel
  3. 12 hr old RR 45 and irregular while crying
  4. 5 hr old Hands & Feet blue bilaterally when sleeping
A
  1. 2 day old laying quietly alert with HR 185 BPM

Tachycardia Resting normal = 120 - 160 BPM. LPN only care for stable

Bulging fontanel are normal when crying

Normal RR is 30 - 60 newborns

Acrocyanosis is normal 2 - 6 hrs after delivery due to poor peripheral circulation

93
Q

Infection that spread to the bloodstream and impact perfusion is aka…

94
Q

Type of fluid that will expand intravascular volume. Needed to Raise BP in sepsis

A

Isotonic

NS .9
LR

95
Q

D5W
.45,.35,.225 NS

Type of solution (Hypo, Isotonic, Hyper)

Biological function

A

Hypotonic

Expand cell

D5W Isotonic in bag, Hypotonic in the body.

96
Q

DKA & HHNS (Hyperosmolar hyperglycemic nonketotic syndrom)

Both get this type of fluid, why

A

Hypotonic

It puts fluid back into the cells

97
Q

Don’t give this type of fluid with ICP Increases Cranial Press, Burn, or Trauma

A

Hypotonic.

Makes cells swell even more

98
Q

When administering a (hypotonic / hypertonic) solution, a nurse should closely watch for signs of hypervolemia:

Elvated blood pressure and breathing difficulties.

(Hypotonic /Hypertonic) solutions move fluid from the intracellular and interstitial spaces to the extracellular compartment, which increases the risk of hypervolemia

A

Hypertonic

99
Q

When giving a hypotonic solution beware of these possible complications

A

hypovolemia, hypotension, or confusion

Cellular edema

Hyponatremia

100
Q

One hour management of Sepsis includes

Measure _____ . Why?
Obtain Blood cultures. Why?
Admin broad spectrum antibiotics
Rapidly infuse crystlloid fluids

Which do you do first? Why?

A

Measure Serum lactate
(tissue perfusion, detect shock, and adjust therapy.Elevated lactate levels = severe hypoperfusion)

Blood cultures are used to determine type of bacteria, what antibiotics it is susceptible to

First, blood draw. Determine type of bacteria Before Broad spectrum antibiotics Interfer with test

101
Q

Is inserting NG tube a sterile procedure?

A

No, clean procedure Not sterile

Because digestive track will kill germs

102
Q

Which statement needs more education from a hep B patient

  1. I must not let family share my silverware
  2. I must not let my family share my towels
  3. I’m looking forward to enjoying intercourse with my spouse when I return home.
  4. I must eat small frequent meals
A
  1. I’m looking forward to enjoying intercourse with my spouse when I return home.

Hep B can live outside the body for atleast 7 days. Any surface with blood or body fluid can transmit HepB

103
Q

1 day old diagnosed with Intrauterine growth retardation, high pitched shrill cry, restless, and irritable with fist sucking behaviors.

What should the LPN do first

  1. Gently massage the clients back q2h
  2. Tightly swaddle client in flexed posistion.
  3. Schedule feedings q3-4h
  4. Encourage eye contact during feedings

Describe nursing interventions

A
  1. Tightly swaddle client in flexed posistion.

Classic symptoms of DRUG Withdrawal

Manifest 12 hrs - 10 days

Nursing interventions
Assess muscle tone, VS, IRRITABILITY
Admin phenobarbital

104
Q

Pediculosis

S&S

Pertussis
Macules & Papules
Presence of nits

What is Pediculosis

A

Pediculosis= Lice

105
Q

GYN clinic

Off white vanginal discharge with curd like appearance and vulvar itching.

What is most important question to ask?

What is the treatment?

A

What kind of birth control do you use? Oral contraceptives cause CANDIDIASIS

Treatment: topical clotrimazole, nystatin (Antifungal)

106
Q

Elastic wrap bandage from toe to mid thigh.

What action should be taken?

  1. Increase friction between skin & bandage
  2. Leave small distal portion of extremity exposed
  3. Use multiple pins to secure
  4. Posistion leg in abduction

Why use an elastic bandage?

A
  1. Leave small distal portion of extremity exposed

Determines color, motion, ans sensitivity of body.

Use elastic bandage:

Muscle sprains and strains
bone fractures

Benefits
Reduce swelling
Restrict blood flow
Decrease pain
Prevent further damage
Limit further damage
Allow continued activity

107
Q

Post laparoscopic cholecystectomy client states: I hate the thought of eating low-fat diet for the rest of my life. Most appropriate response

  1. I will ask the dietician to speak with you.
  2. What do you think is so bad about a low-fat diet
  3. It may not be necessary for you to follow a low-fat diet that long
  4. Atleast you will be alive and not suffering
A
  1. It may not be necessary for you to follow a low-fat diet that long

Fat restrictions is usually lifted with time. The bill billlary ducts swell to hold volume that was once in gallbladder

108
Q

Stroke left-sided paralysis and homonymous hemianopia. Which action should be taken?

  1. Provide morning care from the right side.
  2. Speak loudly and clearly when talking
  3. Reduce light level to reduce glare
  4. Provide client care to reduce the clients energy expenditure
A
  1. Provide morning care from the right side.

Homonymous hemianopia = blindness in each half of the vision field caused by brain damage.

Client must turn head side-to-side to scan field of vision

Approach from nonvisually impaired side. Left sided paralysis = Approach from the right

109
Q

COPD patient is likely to have (Acidosis/ Alkalosis)

110
Q

Type of exercises to be preformed with a cast

A

Isometric

Exp. straighten your leg in the air and hold it for 15 to 20 seconds

111
Q

LRQ pain best intervention

  1. Encourage slow,shallow rhymtic breathing
  2. Massage to RLQ
  3. Heating pad to RLQ
  4. Posistion for comfort
A
  1. Posistion for comfort

Slow, Deep, rhymtic breaths - not shallow
Massage & Heat pad can cause appendicitis- rupture of apendix

112
Q

VS

Temp 103
Pulse 82
RR 14, shallow, unlabored
BP 134/88

CLIENT: 80 F

Why would you retake the temperature with a different thermometer?

A

Because other vital signs are normal

With a fever HR & RR will increase

113
Q

Comatose bed bath

LPN will intervine if the following happens

  1. UAP answers phone while wearing gloves
  2. UAP log rolls client to preform back care
  3. UAP places incontinence pad under client
  4. UAP posistions client on left side, with HOB elevated
A
  1. UAP answers phone while wearing gloves

(Solied gloves need to be removed & Hand Hygine practiced before answering phone)

  1. UAP posistions client on left side, with HOB elevated - This is the correct posistion to prevent aspiration
114
Q

Hip fracture

Affected leg is (Shortened/ Lengthened)

Rotated (Internally/ Externally)

A

Affected leg is shorter and externally rotated

115
Q

Discharge patient from inpatient alcohol treatment.

Which statement by clients wife shows the family is coping adaptively?

  1. My husband will do well as long as I keep him engaged in activities he likes.
  2. My focus is learning how to live my life.
  3. I’m so glad our problems are behind us.
  4. I’ll make sure that the children don’t give my husband any problems.
A
  1. My focus is learning how to live my life. Correct- working to change codependent behavior
  2. My husband will do well as long as I keep him engaged in activities he likes. - Wife accepts responsibility- codependency
  3. I’m so glad our problems are behind us. Unrealistic
  4. I’ll make sure that the children don’t give my husband any problems. - Wife accepts responsibility Codependent behavior
116
Q

Which medication is used for an alcoholic who hasn’t had a drink in 5 hours.

  1. Chlordiazepoxide
  2. Disulfiram
  3. Methadone
  4. Naloxone
A
  1. Chlordiazepoxide - Antianxiety
  2. Disulfiram: (Antiabuse) deters compulsive drinking. Contraindicated with in 12 hrs of alcohol consumption
117
Q

Postexposure to hep A,B, & C profilaxis

A

HBIG (A&B)

None for C

118
Q

Emphysema patient becomes restless & confused. What action should the nurse take next?

  1. Encourage Pursed lip breathing
  2. Measure clients temp
  3. Assess clients K level
  4. Increase oxygen to 5L/ min
A
  1. Encourage Pursed lip breathing
    Helps control rate & depth of breathing
  2. Measure clients temp
  3. Assess clients K level
  4. Increase oxygen to 5L/ min (CAUTION: COPD emphysema should receive low flow oxygen)
119
Q

After intracranial surgery

Medications (4)

HOB

Daily Fluid

A

Osmotic diuretics, corticosteroids, anticonvulsant, & stool softeners (prevents valsalva maneuver)

HOB 30- 45 degrees - promotes Venus return from brain & prevents ICP.

Fluid restriction 1,200 - 1,500

120
Q

Hyperemesis gravidarum is a complication of early pregnancy and has these S&S

A

Severe N&V & Weight loss

121
Q

Emergency cesarean birth

Which will be Delegated to the LPN

  1. Notify blood bank
  2. Insert indwelling catheter
  3. Explain procedure to the clients family
  4. Providing report to the neonatal ICU
A
  1. Insert indwelling catheter

(RN)
1. Notify blood bank
4. Providing report to the neonatal ICU

(HCP)
3. Explain procedure to the clients family

122
Q

Pernicious anemia is caused by ….

Symptoms

A

Failure to absorb vitamin B¹² due to lack of intrinsic factors in gut mucosa

Symptoms: Pallor, jaundice, glossitis, fatigue, weight loss, paresthesia of hands & feet, balance & gait.

123
Q

Chronic bronchitis, audible wheezes, Ox Sat of 85% - 88% 4 hours ago.

Most important action

  1. Give 2 puffs Beclomethasone
  2. Ausculate bilateral breath sounds
  3. Increase oxygen rate to 4L/Minute via mask
  4. Administer 2 puffs Albuterol
A
  1. Administer 2 puffs Albuterol
    (Bronchodilator- opens up airways and allows other medicine to work.)

1.Give 2 puffs Beclomethasone
(Admin Bronchodilator first -rol)
2. Ausculate bilateral breath sounds
No further assessment needed
3. Increase oxygen rate to 4L/Minute via mask (COPD - emphysema & chronic bronchitis cannot tolerate too much oxygen)

124
Q

Proper posistion for a PET brain scan

PET uses radioactive isotopes that are uptake by tissues, damaged tissue more than regular.

What special precaution is needed with urine

A

Flat on back with a small pillow

No urine precautions.

Consume lots of fluid to rid body of isotopes

125
Q

Asthma client prescribed neostigmine IM. Best action for nurse to take.

  1. Administer medicine
  2. Obtain BP & Pulse
  3. Ask pharmacist if med can be given orally
  4. NOTIFY HCP
A
  1. NOTIFY HCP
    Cholinergic causes bronchoconstruction.
  2. Administer medicine
  3. Obtain BP & Pulse
  4. Ask pharmacist if med can be given orally
126
Q

Describe appearance of Addisons disease who has received steroid therapy for several years.

A

Truncal obesity
Purple striations on skin
Moon face
Buffalo hump

127
Q

Which statement by Anorexic is most concerning

  1. My gums bled this morning
  2. I’m getting fatter everyday
  3. Nobody likes me, I’m ugly
  4. I feel dizzy and weak today
A
  1. I feel dizzy and weak today

Masolow needs. Physiological over Psychosocial

128
Q

Why can’t a person with Pneumocystis jiroveci & Kaposi Sarcoma be organ donors

A

Pneumocystis jiroveci (fungal lung infection- immune compromised) & Kaposi Sarcoma (Aids lesions) be organ donors

Aids patients can’t be organ donors

129
Q

After laparoscopic cholecystectomy client reports pain & bloating. Which is best response

  1. Increase intake of fresh fruit & vegetables
  2. I’ll give you prescribed pain medication
  3. We can try talking down the hallway together
  4. You may need an indwelling catherer
A
  1. We can try talking down the hallway together (Carbon Dioxide insufflated during surgery causes pain. Ambulation increases absorption of CO²)

1.Increase intake of fresh fruit & vegetables - No indication of Constipation

  1. I’ll give you prescribed pain medication
  2. You may need an indwelling catherer
130
Q

Which will an LPN assist

  1. Client with MRI of brain in the morning
  2. Unconscious client who needs bed bath
  3. Client in balanced suspension traction
  4. Client with diabetes who needs help bathing
A
  1. Client in balanced suspension traction - stable
131
Q

Client underwent vagotomy with antrectomy for treatment if a duodenal ulcer - developed Dumping syndrome

Which statement indicates more Teaching is needed

  1. I should eat bread with each meal
  2. I should eat smaller meals more often
  3. I should lie down after eating
  4. I should avoid drinking fluids with my meals
A
  1. I should eat bread with each meal
    (Carbs should not be limited with dumping syndrome- protein enchanced)

Rest are true

Laying down after delays stomach emptying time

132
Q

Antrectomy…

A

Treats stomach bleeding & block Removes lower 1/3rd of stomach

Also reduces acid secreting portion of stomach

133
Q

Client with a new colostomy
Teaching was successful when they select

  1. Sausage, sauerkraut, baked potatoes, fresh fruit
  2. Cheese omelet with bran muffin and fresh pineapple
  3. Pork chops, mashed potatoes, turnips, salad.
  4. Baked chicken, boiled potatoes, cooked carrots and yogurt
A
  1. Baked chicken, boiled potatoes, cooked carrots and yogurt

Goal diet 4 - 6 postop colostomy
Low-residue, no gas-forming, odor-producing, laxative or Constipating foods

  1. Sausage, sauerkraut, baked potatoes, fresh fruit (Sausage & Sauekraut gas producing)
  2. Cheese omelet with bran muffin and fresh pineapple (High Fiber - Residue)
  3. Pork chops, mashed potatoes, turnips, salad. (Turnips odor causing, salad residue)
134
Q

Breast feeding is recommended for how long

How many wet diapers daily

How long do new borns sleep between feedings

How long do breast feed babies feed

A

6 - 12 months

6 - 8 diapers daily

2-3hrs day & 4 at night

15 - 20 minutos per breast

135
Q

Breast feeding is recommended for how long

A

6 - 12 months

136
Q

During V fib a client gets defibed.
The purpose of defibrillation is to

Deliver an electric current to the heart that (depolarizes / Repolarizes) myocardial cells. When the cells (depolarize / Repolarize) the ___ node commonly recaptures its role as the pacemaker of the heart

A

Depolarize / Repolarize

SA node (pacemaker of heart)
AV node (gatekeeper of heart - slows down beats)

137
Q

What type of pain is most characteristic of MI

A

Chestpain radiating to neck, jaw, shoulder, back, left arm - unrelieved by Nitroglycerin

Fever
Apprehension
Dizzy
Diaphoresis
Palpitations
SOB

138
Q

First choice for LPN to reduce risk of Pooled airway secretions and decreased chest wall expansion

  1. Chest Percussion
  2. Incentive Spirometry
  3. Posistion Change
  4. Postural Drainage
A
  1. Posistion Change
139
Q

Risk factors

History of varicose veins, hypercoagulation, cardiovascular disease, pregnancy, oral contraceptives, Immobility, recent surgery or injury

A

DVT

Clot formation in a vein secondary to inflammation of vein or partial vein obstruction

140
Q

Risk factors:

History of varicose veins, hypercoagulation, cardiovascular disease, pregnancy, oral contraceptives, Immobility, recent surgery, injury

A

DVT

Clot formation in a vein secondary to inflammation of vein of partial vein obstruction

NCLEX: Mix (18 decks)

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